D i s o rd e r s o f t h e M a s t i c a t o r y

Muscles
Scott S. De Rossi, DMDa,b,c,*, Ilanit Stern, DMD
a
,
Thomas P. Sollecito, DMDd

KEYWORDS
 Masticatory muscles  Persistent orofacial muscle pain  Myalgia  Myofascial pain
 Temporomandibular joint disorder  Fibromyalgia

KEY POINTS
 It is clear that there are several types of disorders of the masticatory muscles, each of
which may have a complex etiology, clinical course, and response to therapy.
 Masticatory muscle disorders include both regional and centrally mediated problems.
Host susceptibility plays a role at several stages of these disorders, including pain mod-
ulation and response to therapy.
 Disorders of the masticatory muscles must be accurately identified and differentiated from
primary temporomandibular joint disorders such as those involving pain from osteoar-
thritis, disc displacement, or jaw dysfunction.

INTRODUCTION

Muscle disorders involving the masticatory muscles have been considered analogous
to skeletal muscle disorders throughout the body.1,2 However, emerging research has
shed new light on the varied etiology, clinical presentation, diagnosis, and treatment of
myofascial pain and masticatory muscle disorders.3–6 This article reviews the etiology
and classification of regional masticatory muscle disorders, the clinical examination of
the patient, and evidence-based treatment recommendations.
Mechanisms behind masticatory muscle pain include overuse of a normally
perfused muscle or ischemia of a normally working muscle, sympathetic reflexes
that produce changes in vascular supply and muscle tone, and changes in psycholog-
ical and emotional states.7 Neurons mediating pain from skeletal muscle are subject to

a
Department of Oral health and Diagnostic Sciences, College of Dental Medicine, Georgia
Regents University, 1120 15th Street, Augusta, GA 30912, USA; b Department of Otolaryngology/
Head & Neck Surgery, Medical College of Georgia, Georgia Regents University, 1120 15th Street,
Augusta, GA 30912, USA; c Department of Dermatology, Medical College of Georgia, Georgia
Regents University, 1120 15th Street, Augusta, GA 30912, USA; d Department of Oral Medicine,
University of Pennsylvania School of Dental Medicine, 240 South 40th Street, Philadelphia, PA
19104-6030, USA
* Corresponding author. Department of Oral health and Diagnostic Sciences, College of Dental
Medicine, Georgia Regents University, 1120 15th Street, Augusta, GA 30912, USA.
E-mail address: [email protected]

Dent Clin N Am 57 (2013) 449–464

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0011-8532/13/$ – see front matter Ó 2013 Published by Elsevier Inc.
450 De Rossi et al

strong modulatory influences. Bradykinin, serotonin, substance P, prostaglandins,

and neuropeptides sensitize nociceptors and can easily sensitize nociceptive endings.
Painful conditions of muscle often result in increased sensitivity of peripheral nocicep-
tors and hyperexcitability in the central nervous system with hyperalgesia.8
Muscle disorders can be divided into regional disorders, such as myalgia associ-
ated with temporomandibular joint (TMJ) disorder, and systemic disorders, such as
pain associated with fibromyalgia.2 The paucity of data on the etiology and pathophys-
iology of muscle pain limits the ability to clearly delineate all groups of muscle disor-
ders. Frequently the clinician must rely on clinical judgment to establish a diagnosis. It
is clear that well-designed controlled trials and additional research is necessary for the
development of validated diagnostic criteria and treatment protocols.3,9–11

CLASSIFICATION OF MASTICATORY MUSCLE DISORDERS

Chronic myalgia of the muscle of mastication (MOM) is one aspect of temporomandib-

ular disorders (TMDs).2,3 Historically, clinicians and researchers have subclassified
TMDs into intracapsular disorders and masticatory muscle disorders such as local
myalgia, myofascial pain, centrally mediated myalgia, myospasm, myositis, myofi-
brotic contracture, and masticatory muscle neoplastic disease.9 Conflicting classifica-
tion schemes and terminology have led to significant confusion among clinicians, and
perhaps inaccurate diagnosis and treatment of patients. In fact, many studies
continue to group muscle pain and painful TMJ disorders together under the term
TMD, although these entities are pathophysiologically and clinically distinct.3,12–14
Although the most common feature of most masticatory muscle disorders is pain,
mandibular dysfunction such as difficulty chewing and mandibular dysfunction may
also occur. The clinician needs to differentiate masticatory muscle disorders from
the primary TMDs such as those that involve pain associated with osteoarthritis,
disc displacement, or jaw dysfunction (Table 1).
The clinical features of masticatory muscle disorders are as follows.

Features of Local Myalgia

 Sore MOM with pain in cheeks and temples on chewing, wide opening, and often
on waking (eg, nocturnal bruxism)
 Bilateral
 Described as stiff, sore, aching, spasm, tightness, or cramping
 Sensation of muscle stiffness, weakness, fatigue
 Possible reduced mandibular range of motion
 Differential diagnosis: myositis, myofascial pain, neoplasm, fibromyalgia

Features of Myofascial Pain

 Regional dull, aching muscle pain
 Trigger points present and pain referral on palpation with/without autonomic
symptoms
 Referred pain often felt as headache
 Trigger points can be inactivated with local anesthetic injection
 Sensation of muscle stiffness and/or malocclusion not verified clinically
 Otologic symptoms including tinnitus, vertigo, and pain
 Headache or toothache
 Decreased range of motion
 Hyperalgesia in region of referred pain
 Differential diagnosis: arthralgia, myositis, local myalgia, neoplasia, fibromyalgia
 Disorders of the Masticatory Muscles 451

Table 1
Diagnostic criteria for masticatory muscle disorders

Disorder Etiology Diagnostic Criteria

Centrally mediated Chronic generalized muscle History of prolonged and continuous
chronic muscle pain pain associated with a muscle pain
comorbid disease Regional dull, aching pain at rest
Pain aggravated by function of
affected muscles
Pain aggravated by palpation
Myalgia (local) Acute muscle pain Regional dull, aching pain during
Protective muscle splinting function
Postexercise soreness No or minimal pain at rest
Muscle fatigue Local muscle tenderness on palpation
Pain from ischemia Absence of trigger points and pain
referral
Myofascial pain Chronic regional Regional dull, aching pain at rest
muscle pain Pain aggravated by function of
affected muscles
Provocation of trigger points alters
pain complaint and reveals referral
pattern
>50% reduction of pain with
vapocoolant spray or local
anesthetic injection to trigger point
followed by stretch
Myofibrotic Painless shortening Limited range of motion
contracture of muscles Firmness on passive stretch (hard stop)
Little or no pain unless involved
muscle is forced to lengthen
Myositis Inflammation secondary Continuous pain localized in muscle
to direct trauma or area following injury or infection
infection Diffuse tenderness over entire muscle
Pain aggravated by function of
affected muscles
Moderate to severe decreased range
of motion due to pain and swelling
Neoplasia Benign or malignant May or may not be painful
Anatomic and structural changes
Imaging and biopsy needed
Myospasm Acute involuntary and Acute onset of pain at rest and during
continuous muscle function
contraction Markedly decreased range of motion
due to continuous involuntary
muscle contraction
Pain aggravated by function of
affected muscles
Increased electromyographic activity
higher than at rest
Sensation of muscle tightness,
cramping, or stiffness

Data from de Leeuw R. Orofacial pain: guidelines for assessment, classification, and management.
The American Academy of Orofacial Pain. 4th edition. Chicago: Quintessence Publishing Co, Inc;
2008.
452 De Rossi et al

Features of Centrally Mediated Myalgia

 Trigger points and pain referral on palpation
 Sensation of muscle stiffness, weakness, and/or fatigue
 Sensation of malocclusion not verified clinically
 Otologic symptoms including tinnitus, vertigo, and pain
 Decreased range of motion
 Hyperalgesia
 No response to treatment directed at painful muscle tissue
 Differential diagnosis: arthralgia, myositis, myofascial pain, local myalgia,
neoplasm, fibromyalgia

Features of Myospasm
 Sudden and involuntary muscle contraction
 Acute malocclusion (dependent on muscles involved)
 Decreased range of motion and pain on function and at rest
 Relatively rare disorder in orofacial pain population
 Differential diagnosis: myositis, local myalgia, neoplasm

Features of Myositis
 History of trauma to muscle or source of infection
 Often continuous pain affecting entire affected muscle
 Pain aggravated by function
 Severe limited range of motion

Features of Myofibrotic Contracture

 Not usually painful
 Often follows long period of limited range of motion or disuse (eg, intermaxillary
fixation)
 History of infection or trauma is common
 Differential diagnosis: TMJ ankylosis, coronoid hypertrophy

Features of Masticatory Muscle Neoplasia

 Pain may or may not be present
 Anatomic and structural changes: tumors may be in muscles or masticatory
spaces
 Swelling, trismus, paresthesias, and pain referred to teeth
 Positive findings on imaging or biopsy
Some clinicians have stressed classifying myogenic disorders based on an
anatomic system allowing for a simpler diagnostic process, because evaluation
of the patient involves careful palpation of the masticatory muscles and
joints.13,15,16 The clinician needs to determine the etiology and pathophysiology
that occur with the various masticatory muscle disorders, such as disorders caused
by trauma. A thorough history and clinical examination, an understanding of pain
neuroanatomy and neurophysiology, and an in-depth knowledge of research on
muscle pain are important.16–18 Various causes of myogenous pain are summarized
in Table 2.
Recently a new term, persistent orofacial muscle pain (POMP), has been intro-
duced, to more accurately reflect the interplay between peripheral nociceptive sour-
ces in muscles, faulty central nervous system components, and decreased coping
 Disorders of the Masticatory Muscles 453

Table 2
Etiology of myogenous pain

Etiology Criteria
Focal myalgia from direct History of trauma preceding pain onset
trauma Subjective pain in muscles with function
Pain reproduced on palpation
Primary myalgia due to No history of trauma
parafunction Subjective pain in muscle with function
Pain reproduced on palpation
No trigger points
Secondary myalgia due to History of recent joint, oral soft tissue, or pulpal disease or
active local pathology or medication (eg, serotonin-selective reuptake inhibitors) that
recent medications coincides with muscle pain
Subjective pain in muscle with function
Pain reproduced on palpation
Myofascial pain No history of recent trauma
Subjective pain in muscles with function
Pain reproduced on palpation
Trigger points and pain referral
Diffuse chronic muscle pain Subjective pain in multiple sites aggravated by function
and fibromyalgia Widespread pain involving more than 3 body quadrants
>3 mo duration
Strong pain on palpation in 11 of 18 body sites

Data from Clark GT, Minakuchi H. Oral appliances. In: Laskin DM, Greene CS, Hylander WL, editors.
Temporomandibular disorders: an evidence-based approach to diagnosis and treatment. Chicago:
Quintessence; 2006. p. 377–90.

ability.3 POMP likely shares mechanisms with tension-type headache, regional myo-
fascial pain, and fibromyalgia, and has genetically influenced traits that determine
pain modulation and pharmacogenomics interacting with psychological traits to affect
disease onset, clinical progression, and pain experience.3,4 To date, these factors
cannot be identified in the individual patient sufficiently enough to tailor focused,
mechanism-based treatment. POMP is consistent with the condition often referred
to as centrally mediated myalgia and, as such, treatment needs to be redirected
from local and regional therapies to systemic and central ones.

CLINICAL EXAMINATION OF THE PATIENT

The most effective approach for the diagnosis masticatory muscle pain involves care-
ful review of the chief complaint, the history of the present illness (Table 3), the dental,
medical, and psychosocial behavioral histories (Box 1), and a comprehensive evalua-
tion of the head and neck including a cranial nerve assessment (Table 4).2 In addition,
imaging modalities may be important in ruling out other conditions. No one physical
finding can be relied on to establish a diagnosis; rather, a pattern of abnormalities
may suggest the source of the problem and diagnosis.11 However, masticatory mus-
cle tenderness on palpation is the most consistent examination feature present in
TMDs.19–24 In fact, the clinical features that distinguish patients from non-TMD or
masticatory muscle pain most consistently reported in the literature are: restricted
passive mouth opening without pain; masticatory muscle tenderness on palpation;
limited maximal mouth opening; and an uncorrected deviation on maximum mouth
opening and tenderness on muscle or joint palpation.2,19–24
454 De Rossi et al

Table 3
History of the present illness: pain characteristics

Quality Common patient descriptors: dull, sharp, tight, aching,

tired, etc
Location Unilateral vs bilateral
Pain confined to a single muscle or referred to a distant area
Intensity On a scale of 1–10
Mild, moderate, or severe
Onset, duration, pattern How long has the pain been present?
What if anything caused the pain? (eg, trauma)
What has been the course of pain since its onset? (eg, episodic,
constant, fluctuating)
Modifiers What exacerbates or diminishes the pain?
Does anything you do or use help or worsen pain?
Chronicity How long has the pain been present?
Comorbid symptoms Are there any other conditions or symptoms associated with
and signs pain? (eg, depression, acute anxiety, nausea/vomiting,
tearing, visual changes, dizziness, numbness/tingling,
weakness, generalized pain)

Box 1
Questions regarding oral behavior and parafunction

DO YOU:
Clench or grind your teeth when asleep?
Sleep in a position that puts pressure on your jaw? (eg, side, stomach)
Clench or press teeth together while awake?
Touch or hold teeth together while eating?
Hold, tighten, or tense muscles without clenching or touching teeth together?
Hold out or jut jaw forward or to side?
Press tongue between teeth?
Bite, chew, or play with tongue, cheeks, or lips?
Hold jaw in rigid or tense position to brace or protect jaw?
Bite or hold objects between teeth (eg, pens, pipe, hair, fingernails, and so forth)?
Use chewing gum?
Play musical instruments that involve mouth or jaw?
Lean with hand on jaw or chin?
Chew food on one side only?
Eat between meals (food requiring lots of chewing)?
Talk at length?
Sing?
Yawn excessively?
Hold telephone between head and shoulder?

Data from Ohrbach R, Markiewicz M, McCall WD Jr. Oral Behaviors Checklist: performance val-
idity of targeted behaviors [abstract]. J Dent Res 2004;83:(Spec Issue A):T27–45.
 Disorders of the Masticatory Muscles 455

Table 4
Physical examination directed toward mandibular dysfunction

Examination Observations
Inspection Facial asymmetry, swelling, and masseter and temporal muscle
hypertrophy
Opening pattern (corrected and uncorrected deviations,
uncoordinated movements, limitations)
Assessment of range of Maximum opening with comfort, with pain, and with clinician
mandibular movement assistance
Maximum lateral and protrusive movements
Palpation examination Masticatory muscles
Temporomandibular joints
Neck muscles and accessory muscles of the jaw
Parotid and submandibular areas
Lymph nodes
Provocation tests Static pain test (mandibular resistance against pressure)
Pain in the joints or muscles with tooth clenching
Reproduction of symptoms with chewing (wax, sugarless gum)
Intraoral examination Signs of parafunction (cheek or lip biting, accentuated linea
alba, scalloped tongue borders, occlusal wear, tooth
mobility, generalized sensitivity to percussion, thermal
testing, multiple fractures of enamel, restorations)

Data from Refs.2,19–24,27

Objective determination of the presence or absence of parafunctional jaw behavior

is challenging.25 Although the presence of these behaviors may not have proven diag-
nostic validity, their assessment remains important because it provides potential
causative or perpetual factors and/or effects on the masticatory system.26 An oral
behavior checklist is a useful instrument for determining the presence or awareness
of parafunctional behaviors.27
Interincisor separation (plus or minus the incisor overlap in centric occlusion) pro-
vides the measure of mandibular movement. Maximum interincisal opening (MIO)
should be measured using a ruler without pain, as wide as possible with pain, and
after opening with clinician assistance. Mouth opening with assistance is accom-
plished by applying mild to moderate pressure against the upper and lower incisors
with the thumb and index finger. Passive stretching often allows the clinician to
assess and differentiate the limitation of opening caused by a muscle or joint problem
by comparing assisted opening with active opening. This action provides the exam-
iner with the quality of resistance at the end of the movement. Often, muscle restric-
tions are associated with a soft end-feel and result in an increase of more than 5 mm
above the active opening (wide opening with pain), whereas joint disorders such as
acute nonreducing disc displacements have a hard end-feel and characteristically
limit assisted opening to less than 5 mm (normal MIO is w40 mm; range
35–55 mm). Measurements of lateral movement are made with the teeth slightly sepa-
rated, measuring the displacement of the lower midline from the maxillary midline,
and adding or subtracting the lower-midline displacement at the start of movement.
Protrusive movement is measured by adding the horizontal distance between the up-
per and lower central incisors and adding the distance the lower incisors travel
beyond the upper incisors; normal lateral and protrusive movements are approxi-
mately 7 mm.
456 De Rossi et al

The primary finding related to masticatory muscle palpation is pain; however, the
methods for palpation are not standardized in clinical practice.28 The amount of pres-
sure to apply and the exact sites that are most likely associated with TMD are un-
known. Some clinicians have recommended attempting to establish a baseline (to
serve as a general guide or reference) by squeezing a muscle between the index finger
and thumb or by applying pressure in the center of the forehead or thumbnail to gauge
what pressure becomes uncomfortable.9 The Research Diagnostic Criteria for Tempo-
romandibular Disorders (RDC/TMD) guidelines recommend 1 lb (0.45 kg) of pressure
for the joint and 2 lb (0.9 kg) of pressure for the muscles. Palpation should be accom-
panied by: asking the patient about the presence of pain at the palpation site; whether
palpation produces pain spread or referral to a distant site; and whether palpation re-
produces the pain the patient has been experiencing.9,29 Reproducing the site and the
character of the pain during the examination procedure helps identify the potential
source of the pain. The distant origin of referred pain can also be identified by
palpation.29
Palpation of the muscles for pain should be done with the muscles in a resting
state.29 There are no standardized methods of assessing the severity of palpable
pain, and the patient should be asked to rate the severity by using a scale (eg, a
numeric scale from 1 to 10, a visual analog scale, or a ranking such as none, mild,
moderate, or severe). The RDC/TMD recommends using the categories of pressure
only, mild pain, moderate pain, and severe pain.9 These ratings may also be useful
in assessing treatment progress in addition to asking patients what percentage of
improvement they may feel. The lateral pterygoid is in a position that does not allow
access for adequate palpation examination, even though there are examination pro-
tocols and descriptions for palpating this muscle.
Patients with TMDs often have musculoskeletal problems in other regions (neck,
back, and so forth).30 The upper cervical somatosensory nerves send branches that
synapse in the spinal trigeminal nucleus, which is one proposed mechanism to explain
referral of pain from the neck to the orofacial region and masticatory muscles.31–33 The
sternocleidomastoid and trapezius muscles are often part of cervical muscle disor-
ders, and may refer pain to the face and head. Other cervical muscle groups to include
in the palpation examination include the paravertebral (scalene) and suboccipital
muscles.
Injections of anesthetics into the TMJ or selected masticatory muscles may help
confirm a diagnosis. Elimination of or a significant decrease in pain and improved
jaw motion should be considered a positive test result. Diagnostic injections may
also be helpful in differentiating pain arising from joints or muscle.2,29 In situations
where a joint procedure is being considered, local anesthetic injection of the joint
may confirm the joint as the source of pain. Injecting trigger points or tender areas
of muscle should eliminate pain from the site and should also eliminate referred
pain associated with the injected trigger point. Interpretation of injections in the
context of all the diagnostic information is vital, because a positive result does not
ensure a specific diagnosis. Recently, the use of botulinum toxin (Botox) has been
advocated for trigger-point injections and for the management of tension-type head-
ache.3,4,6,29 In several case-control studies and randomized trials, descriptive analysis
showed that improvements in both objective (range of mandibular movements) and
subjective (pain at rest; pain during chewing) clinical outcome variables were higher
in Botox-treated groups than in the placebo-treated subjects. Patients treated with
Botox had a higher subjective improvement in their perception of treatment efficacy
than placebo-treated subjects.2,6,29
 Disorders of the Masticatory Muscles 457

TREATMENT OF MASTICATORY MUSCLE DISORDERS

It is important for the clinician treating patients with TMDs to distinguish clinically sig-
nificant disorders that require therapy from incidental findings in a patient with facial
pain attributable to other causes.2 TMJ abnormalities are often discovered on routine
examination, and may not require treatment such as with asymptomatic clicking of the
TMJ. The need for treatment is largely based on the level of pain and dysfunction as
well as the progression of symptoms. With respect to disorders of MOM, the principles
of treatment are based on a generally favorable prognosis and an appreciation of the
lack of clinically controlled trials indicating the superiority, predictability, and safety of
treatments presently available. The literature suggests that many treatments have
some beneficial effect, although this effect may be nonspecific and not directly related
to the particular treatment.1–3,9
According to the American Association of Dental Research, it is strongly recommen-
ded that, unless there are specific and justifiable indications to the contrary, treatment of
TMD patients, including those with disorders of MOM, initially should be based on the
use of conservative, reversible, and evidence-based therapeutic modalities.34 Studies
of the natural history of many TMDs suggest that they tend to improve or resolve over
time.12,14,15,19,21,35 Although no specific therapies have been proved to be uniformly
effective, many of the conservative modalities have proved to be at least as effective
as most forms of invasive treatment in providing symptomatic relief. Because such mo-
dalities do not produce irreversible changes, they present much less risk of producing
harm. Professional treatment should be augmented with a home-care program whereby
patients are taught about their disorder and how to manage their symptoms.34,36
Treatments that are relatively accessible, not prohibitive owing to expense, safe,
and reversible should be given priority, for example: education; self-care; physical
therapy; intraoral appliance therapy; and short-term pharmacotherapy, behavioral
therapy, and relaxation techniques (Table 5). There is evidence to suggest that multi-
modal therapy and combining treatments produces a better outcome.5,37 Occlusal
therapy continues to be recommended by some clinicians as an initial treatment or
as a requirement to prevent recurrent symptoms. However, research does not support
occlusal abnormalities as a significant etiologic factor in TMD including masticatory
muscle disorders.2,38–41
Avoidance therapy and cognitive awareness plays a vital role in patient care but has
little scientific evidence to support its use.2,17,24,25 Generally speaking, common sense
dictates that if something hurts, it should be avoided. Four behaviors should be
avoided in the patient with masticatory muscle pain:

1. Avoidance of clenching by reproducing a rest position where the patient’s lips are
closed but teeth are slightly separated
2. Avoidance of poor head and neck posture
3. Avoidance of testing the jaw or jaw joint clicking
4. Avoidance of other habits such as nail biting, lip biting, gum chewing, and so forth
(Box 2).
Many patients report benefit from heat or ice packs applied to painful MOM. The
local application of heat can increase circulation and relax muscles, whereas ice
may serve as an anesthetic for painful muscles. In addition, stretch therapy must be
part of a self-care program. Stretches should be done multiple times daily to maximize
effectiveness. The most effective stretching exercise is passive stretching, summa-
rized in Box 3.
458 De Rossi et al

Table 5
Initial treatment of masticatory muscle disorders

Treatment Component Description

Education Explanation of the diagnosis and treatment
Reassurance about the generally good prognosis for recovery and
natural course
Explanation of patient’s and doctor’s roles in therapy
Information to enable patient to perform self-care
Self-care Eliminate oral habits (eg, tooth clenching, chewing gum)
Provide information on jaw care associated with daily activities
Physical therapy Education regarding biomechanics of jaw, neck, and head posture
Passive modalities (heat and cold therapy, ultrasound, laser, TENS)
Range of motion exercises (active and passive)
Posture therapy
Passive stretching, general exercise and conditioning program
Intraoral appliance Cover all the teeth on the arch the appliance is seated on
therapy Adjust to achieve simultaneous contact against opposing teeth
Adjust to a stable comfortable mandibular posture
Avoid changing mandibular position
Avoid long-term continuous use
Pharmacotherapy NSAIDs, acetaminophen, muscle relaxants, antianxiety agents,
tricyclic antidepressants
Behavioral/relaxation Relaxation therapy
techniques Hypnosis
Biofeedback
Cognitive-behavioral therapy

Abbreviations: NSAIDs, nonsteroidal anti-inflammatory drugs; TENS, transcutaneous electrical

nerve stimulation.
Data from Refs.2,17,40,41

Physiotherapy helps to relieve musculoskeletal pain and restore normal function by

altering sensory input; reducing inflammation; decreasing, coordinating, and strength-
ening muscle activity; and promoting the rehabilitation of tissues.14 A licensed profes-
sional therapist is recommended for treatment. Despite the absence of well-controlled
clinical trials, physiotherapy is a well-recognized effective and conservative therapy
for many disorders of the MOM.

Physical Therapy Techniques

 Posture training
 Exercises
 Mobilization

Physical Agents and Modalities

 Electrotherapy and transcutaneous electrical nerve stimulations (TENS)
 Ultrasound
 Iontophoresis
 Vapocoolant spray
 Trigger-point injections with local anesthetic or Botox
 Acupuncture
 Laser treatment
 Disorders of the Masticatory Muscles 459

Box 2
Patient’s instructions for self-care

 Be aware of habits or patterns of jaw use.

 Avoid tooth contact except during chewing and swallowing.
 Notice any contact the teeth make.
 Notice any clenching, grinding, gritting, or tapping of teeth, or any tensing or rigid
holding of the jaw muscles.
 Check for tooth clenching while driving, studying, doing computer work, reading, or
engaging in athletic activities; when at work or in social situations; and when
experiencing overwork, fatigue, or stress.
 Position the jaw to avoid tooth contacts.
 Place the tip of the tongue behind the top teeth and keep the teeth slightly apart;
maintain this position when the jaw is not being used for functions such as speaking
and chewing.
 Modify your diet.
 Choose softer foods and only those foods that can be chewed without pain.
 Cut foods into smaller pieces; avoid foods that require wide mouth opening and biting off
with the front teeth, or foods that are chewy and sticky and that require excessive mouth
movements.
 Do not chew gum.
 Do not test the jaw.
 Do not open the mouth wide or move the jaw around excessively to assess pain or motion.
 Avoid habitually maneuvering the jaw into positions to assess its comfort or range.
 Avoid habitually clicking the jaw if a click is present.
 Avoid certain postures.
 Do not lean on or cup the chin when performing desk work or at the dining table.
 Do not sleep on the stomach or in postures that place stress on the jaw.
 Avoid elective dental treatment while symptoms of pain and limited opening are present.
 During yawning, support the jaw by providing mild pressure underneath the chin with the
thumb and index finger or with the back of the hand.
 Apply moist hot compresses to the sides of the face and to the temple areas for 10 to
20 minutes twice daily.

SPLINT THERAPY

Splints, orthotics, orthopedic appliances, bite guards, nightguards, or bruxing guards

are used in TMD treatment, and often for disorders of masticatory muscles.2 Their use
is considered to be a reversible part of initial therapy. Several studies on splint therapy
have demonstrated a treatment effect, although researchers disagree as to the reason
for the effect.5,14,15 In a review of the literature on splint therapy, Clark and col-
leagues17,24 found that patients reported a 70% to 90% improvement with splint ther-
apy. A recent review of the research on splint therapy suggests that using a splint as
part of therapy for masticatory myalgia, arthralgia, or both may be supported by the
literature in case-control studies.40 Conversely, there is insufficient evidence on review
of published randomized controlled trials to support the use of stabilization splint
460 De Rossi et al

Box 3
Patient’s exercise instructions
Certain exercises can help you relieve the pain that comes from tired, cramped muscles. They
can also help if you have difficulty opening your mouth. The exercises described work by help-
ing you relax tense muscles and are referred to as “passive stretching.” The more often you do
these exercises, the more you’ll relax the muscles that are painfully tense.
Do these exercises 2 times daily:
1. Ice down both sides of the face for 5 to 10 minutes before beginning (ice cubes in sandwich
bags or packs of frozen vegetables work well for this).
2. Place thumb of one hand on the edge of the upper front teeth and the index and middle
fingers of the other hand on the edge of the lower front teeth, with the thumb under
the chin.
3. The starting position for the stretches is with the thumb of the one hand and index finger of
the other hand just touching.
4. Gently pull open the lower jaw, using the hand only, until you feel a passive stretch, not
pain, hold for 10 seconds, then allow the lower jaw to close until the thumb and index
finger are once again contacting; it is crucial that when doing these exercises not to use the
jaw muscles to open and close, but rather manual manipulation only (the fingers do all the
work!).
5. Repeat the above stretching action 10 times, performing 2 to 3 sets per day, 1 in the morning
and 1 or 2 in the evening.
6. When finished with the exercises, one can place moist heat to both sides of the face for 5 to
10 minutes (heating a wet washcloth in the microwave for about 1 minute works well for
this).

Demonstration of a passive stretch using the fingers.

therapy over other active interventions in the treatment of myofascial pain. Splints
appear to be better than no treatment, but only as effective as other active interven-
tions for myofascial pain.40–43 A systematic review and meta-analysis by Ebrahim
and colleagues37 reviewed 11 eligible studies of 1567 patients, and demonstrated
promising results for pain reduction, very low evidence for an effect on quality of
life, and significant research bias (Box 4).

PHARMACOLOGIC THERAPY

Both clinical and controlled experimental studies suggest that medications may pro-
mote patient comfort and rehabilitation when used as part of comprehensive
 Disorders of the Masticatory Muscles 461

Box 4
Splint therapy

 The appliance most commonly used is described as a stabilization appliance or muscle

relaxation splint
 Designed to cover a full arch and adjusted to avoid altering jaw position or placing
orthodontic forces on the teeth
 Should be adjusted to provide bilateral, even contact with the opposing teeth on closure
and in a comfortable mandibular posture
 Should be reexamined periodically and readjusted as necessary to accommodate changes
in mandibular posture or muscle function that may affect the opposing tooth contacts on
the appliance
 At the beginning of appliance therapy, a combination of appliance use during sleep and for
periods during waking hours is appropriate
 Factors such as tooth clenching when driving or exercising, or pain symptoms that tend to
increase as the day progresses, may be better managed by increasing splint use during
these times
 To avoid the possibility of occlusal change, no appliance should not be worn continuously (ie,
24 hours per day) over prolonged periods
 Full-coverage appliance therapy during sleep is a common practice to reduce the effects of
bruxism and is not usually associated with occlusal change

treatment. Although there is a tendency for clinicians to rely on “favorite” agents, no

single medication has proved to be effective for the entire spectrum of
TMDs.2–4,17,24 With respect to pain associated with disorders of the MOM, analgesics,
nonsteroidal anti-inflammatory agents, corticosteroids, benzodiazepines, muscle re-
laxants, and low-dose antidepressants have shown efficacy. Many of the medications
used for fibromyalgia can be used for patients with masticatory muscle disorders
(Table 6).30 These agents are versatile and effective at treating the multiple symptoms
associated with chronic muscle pain. The medications used for myofascial pain and
masticatory muscle disorders are discussed in greater detail elsewhere in this issue
by Nasri-Heir and colleagues.

Table 6
Medications used for fibromyalgia that may be beneficial for masticatory muscle pain

Medication Class Effect

Tricyclic antidepressants (TCAs) Moderately helpful for pain
More side effects (xerostomia, fatigue)
Serotonin-selective reuptake Fewer side effects than TCAs
inhibitors More effective for anxiety/depression than for pain
Muscle relaxants Moderately helpful for local muscle pain
More side effects (xerostomia, sedation)
Serotonin-norepinephrine Moderately helpful for fibromyalgia-related pain
reuptake inhibitors
Low-potency opioids Moderately helpful for fibromyalgia-related pain
NSAIDs Helpful for acute inflammatory pain but not chronic muscle
pain or fibromyalgia-related pain
462 De Rossi et al

SUMMARY

It is clear that there are several types of disorders of the masticatory muscles, each of
which may have a complex etiology, clinical course, and response to therapy. Masti-
catory muscle disorders include both regional and centrally mediated problems. Host
susceptibility plays a role at several stages of these disorders, including pain modula-
tion and response to therapy. Disorders of the masticatory muscles must be accu-
rately identified and differentiated from primary TMJ disorders such as those
involving pain from osteoarthritis, disc displacement, or jaw dysfunction.44

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