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Current Pain and Headache Reports

, Volume 5, Issue 5, pp 421–431 | Cite as

Nonpharmacologic approaches to the management of myofascial temporomandibular disorders

  • Jeffrey J. Sherman
  • Dennis C. Turk
Article

Abstract

The temporomandibular disorders (TMDs) are a heterogeneous group of painful musculoskeletal conditions that include masticatory muscle pain. TMD is a common condition but its etiology is, as yet, poorly understood. Although TMD can be quite disabling, most patients presenting with symptoms improve regardless of treatment type. This article focuses on nonpharmacologic treatments for TMD; recent articles on etiology, assessment, and treatment for this muscle pain condition are reviewed.

Psychological approaches include biofeedback, minimal therapist contact interventions, relaxation, and cognitivebehavioral therapy. We suggest that treatments based on the biopsychosocial model of illness should be used concurrently with treatments focusing only on the biomedical aspects of TMD. Psychological treatments need not be viewed as a treatment of last resort, but rather should be delivered concurrent with biomedical treatments. We present data from recent clinical trials showing that treatment-matching approaches tailoring psychological and educational treatments to psychosocial profiles, delivered concurrent with usual dental care, results in greater and more sustained improvement than usual dental care alone. As such, treatment for TMD should be viewed in much the same way as treatment for most other chronic pain conditions, that is, from a multidisciplinary perspective.

Keywords

Chronic Pain Condition Myofascial Pain Temporomandibular Disorder Cognitive Behavior Therapy Intervention Occlusal Splint 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References and Recommended Reading

  1. 1.
    National Institutes of Health: Management of temporomandibular disorders: National Institutes of Health Technology Assessment Conference statement. J Am Dent Assoc 1996, 127:1595–1606.Google Scholar
  2. 2.
    Zarb GA, Mock D: On emphasizing a scientifically prudent approach to the management of temporomandibular disorders. J Orofac Pain 1999, 23:221–222.Google Scholar
  3. 3.
    Goulet JP, Lavigne GJ, Lund JP: Jaw pain prevalence among French speaking Canadians in Quebec and related symptoms of temporomandibular disorders. J Dent Res 1995, 74:1738–1744.PubMedCrossRefGoogle Scholar
  4. 4.
    Von Korff M, Dworkin SF, LeResche L, et al.: An epidemiologic comparison of pain complaints. Pain 1988, 32:173–183.CrossRefGoogle Scholar
  5. 5.
    Drangsholt M, LeResche L: Temporomandibular disorder pain. In Epidemiology of Pain. Edited by Crombie IK. Seattle, WA: IASP Press; 2000:203–233. Synthesizes data on the epidemiology of the TMDs. It provides useful information on the prevalence of TMD in different countries and data on the age of onset and progression of these disorders across the life span.Google Scholar
  6. 6.
    Greene CS: Temporomandibular disorders: the evolution of concepts. In The Temporomandibular Joint: A Biological Basis for Clinical Practice. Edited by Sarnat BG, Laskin DM. Philadelphia: WB Saunders Co.; 1992:298–315.Google Scholar
  7. 7.
    Hodges JM: Managing temporomandibular joint syndrome. Laryngoscope 1990, 100:60–66.PubMedCrossRefGoogle Scholar
  8. 8.
    DeLeeuw R, Boering G, Stegenga B, et al.: Symptoms of temporomandibular joint osteoarthrosis and internal derangement 30 years after non-surgical treatment. Cranio 1995, 13:81–88.Google Scholar
  9. 9.
    Greene CS: Etiology of temporomandibular disorders. Semin Orthod 1995, 1:222–228.PubMedCrossRefGoogle Scholar
  10. 10.
    McNeill C: History and evolution of TMD concepts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997, 83:51–60.PubMedCrossRefGoogle Scholar
  11. 11.
    Stohler CS: Muscle-related temporomandibular disorders. J Orofac Pain 1999, 13:273–284. Provides an explanation of alternative etiologic models for muscle-related TMD.PubMedGoogle Scholar
  12. 12.
    Svensson P, Arendt-Nielson L: Clinical and experimental aspects of temporomandibular disorders. Curr Rev Pain 2000, 4:158–165.PubMedGoogle Scholar
  13. 13.
    Turk DC, Penzien DB, Rains JC: Temporomandibular disorders. In Handbook of Rehabilitation Psychology. Edited by Goreczny AJ. New York: Plenum Press; 1995:55–77.Google Scholar
  14. 14.
    Rollman GB, Gillespie JM: The role of psychosocial factors in temporomandibular disorders. Curr Rev Pain 2000, 4:71–81. Synthesizes the psychological literature regarding TMD. It explains how psychosocial characteristics can influence illness expression.PubMedGoogle Scholar
  15. 15.
    Marbach JJ: Medically unexplained chronic orofacial pain. Med Clin North Am 1999, 83:691–710.PubMedCrossRefGoogle Scholar
  16. 16.
    Hansson LG, Hansson T, Petersson A: A comparison between clinical and radiological findings in 259 temporomandibular joint patients. J Prosthet Dent 1983, 50:89–94.PubMedCrossRefGoogle Scholar
  17. 17.
    Kircos LT, Ortendahl DA, Mark AS: Magnetic resonance imaging of the TMJ disc in asymptomatic volunteers. J Oral Maxillofac Surg 1987, 45:397–401.CrossRefGoogle Scholar
  18. 18.
    Dworkin SF, LeReche L: Research diagnostic criteria for temporomandibular disorders: review, criteria, examinations and specifications, critique. J Craniomandibular Disord Facial Oral Pain 1992, 6:301–355.Google Scholar
  19. 19.
    Robinson PD: A review of temporomandibular joint pain. Pain Rev 1995, 2:138–151.Google Scholar
  20. 20.
    Svensson P: Pain mechanisms in myogenous temporomandibular disorders. Pain Forum 1997, 6:158–165.Google Scholar
  21. 21.
    Maixner W, Fillingim R, Booker D, et al.: Sensitivity of patients with temporomandibular disorders to experimentally evoked pain. Pain 1995, 63:85–102.CrossRefGoogle Scholar
  22. 22.
    Maixner W, Fillingim R, Kincaid S, et al.: Relationship between pain sensitivity and resting arterial blood pressure in patients with temporomandibular disorders. Psychosom Med 1997, 59:503–511.PubMedGoogle Scholar
  23. 23.
    Maixner W, Fillingim R, Sigurdsson A, et al.: Sensitivity of patients with temporomandibular disorders to experimentally evoked pain: evidence for altered temporal summation of pain. Pain 1998, 76:71–81. This research provides an excellent rationale and experimental test of the central sensitization hypothesis for altered pain sensitivity in patients with TMD pain.PubMedCrossRefGoogle Scholar
  24. 24.
    Korszun A, Papadopoulos E, Demitrack M, et al.: The relationship between temporomandibular disorders and stress associated syndromes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998, 86:416–420.PubMedCrossRefGoogle Scholar
  25. 25.
    Demitrack MA, Crofford LJ: Evidence for pathophysiologic implications of hypothalamic-pituitary-adrenal axis dysregulation in fibromyalgia and chronic fatigue syndrome. Ann N Y Acad Sci 1998, 840:684–697.PubMedCrossRefGoogle Scholar
  26. 26.
    Jones DA, Rollman GB, Brook RI: The cortisol response to psychological stress in temporomandibular dysfunction. Pain 1997, 72:171–182.PubMedCrossRefGoogle Scholar
  27. 27.
    Flor H, Birbaumer N, Schugens MM, et al.: Symptom specific psychological responses in chronic pain patients. Psychophysiology 1992, 29:452–460.PubMedCrossRefGoogle Scholar
  28. 28.
    Carlson CR, Reid KI, Curran SL, et al.: Psychological and physiological parameters of masticatory muscle pain. Pain 1998, 76:297–307.PubMedCrossRefGoogle Scholar
  29. 29.
    Gatchel RJ, Garafalo JP, Ellis E, et al.: Major psychological disorders in acute and chronic TMD: an initial examination. J Am Dent Assoc 1996, 127:1365–1374.PubMedGoogle Scholar
  30. 30.
    Kight M, Gatchel RJ, Wesley L: Temporomandibular disorders: evidence for significant overlap with psychopathology. Health Psychol 1999, 18:177–182.PubMedCrossRefGoogle Scholar
  31. 31.
    Dworkin SF: Behavioral characteristics of chronic temporomandibular disorders: diagnosis and assessment. In Progress in Pain Research and Management. Edited by Sessle BJ et al. Seattle, WA: IASP Press; 1995:175–192.Google Scholar
  32. 32.
    Dohrenwend BP, Raphael KG, Marbach JJ, et al.: Why is depression comorbid with chronic myofascial face pain? A family study test of alternative hypotheses. Pain 1999, 83:183–192.PubMedCrossRefGoogle Scholar
  33. 33.
    Dworkin SF, Von Korff MR, LeResche L: Multiple pains and psychiatric disturbance: an epidemiologic investigation. Arch Gen Psychiatry 1990, 47:239–244.PubMedGoogle Scholar
  34. 34.
    Von Korff M, LeResche L, Dworkin SF: First onset of common pain symptoms: a prospective study of depression as a risk factor. Pain 1993, 55:251–258.CrossRefGoogle Scholar
  35. 35.
    McCreary CP, Clark GT, Merril RL, et al.: Psychological distress and diagnostic subgroups of temporomandibular disorder patients. Pain 1991, 44:29–34.PubMedCrossRefGoogle Scholar
  36. 36.
    Dworkin SF, Von Korff M, LeResche L: Epidemiologic studies of chronic pain: a dynamic-ecologic perspective. Ann Behav Med 1992, 14:3–11.Google Scholar
  37. 37.
    Turk DC, Rudy TE, Kubinski JA, et al.: Dysfunctional TMD patients: evaluating the efficacy of a tailored treatment protocol. J Consult Clin Psychol 1996, 64:139–146.PubMedCrossRefGoogle Scholar
  38. 38.
    Oken D: Multiaxial diagnosis and the psychosomatic model of disease. Psychosom Med 2000, 62:171–175.PubMedGoogle Scholar
  39. 39.
    Dworkin SF, Sherman JJ: Relying on objective and subjective measures of chronic pain: guidelines for use and interpretation. In Handbook of Pain Assessment. Edited by Turk DC, Melzack R. New York: Guilford Press; 1992:429–446.Google Scholar
  40. 40.
    McNeill C: American Academy of Craniomandibular Disorders: Craniomandibular Disorders—Guidelines for Evaluation, Diagnosis and Management. Chicago, IL: Quintessence; 1990.Google Scholar
  41. 41.
    Bouckoms AJ, Keith DA: Pharmacologic treatment for chronic facial pain. Curr Opin Dent 1991, 1:480–484.PubMedGoogle Scholar
  42. 42.
    Pettengill CA, Reisner-Keller L: The use of tricyclic antidepressants for the control of chronic orofacial pain. Cranio 1997, 15:53–56.PubMedGoogle Scholar
  43. 43.
    Plesh O, Curtis D, Levine J, et al.: Amitriptyline treatment of chronic pain in patients with temporomandibular disorders. J Oral Rehabil 2000, 27:834–841.PubMedCrossRefGoogle Scholar
  44. 44.
    Clark GT, Adler RC: A critical evaluation of occlusal therapy: occlusal adjustment procedures. J Am Dent Assoc 1985, 110:743–750.PubMedGoogle Scholar
  45. 45.
    Rodrigues-Garcia RC, Sakai S, Rugh JD, et al.: Effects of major Class II occlusal corrections on temporomandibular signs and symptoms. J Orofac Pain 1998, 12:185–192.PubMedGoogle Scholar
  46. 46.
    Pierce CJ, Weyant RJ, Block HM, et al.: Dental splint prescription patterns: a survey. J Am Dent Assoc 1995, 126:248–254.PubMedGoogle Scholar
  47. 47.
    Glaros AG, Glass EG: Temporomandibular disorders. In Psychophysiological Disorders: Research and Clinical Applications. Edited by Gatchel RJ, Blanchard EB. Washington, DC: American Psychological Association; 1996:299–356.Google Scholar
  48. 48.
    Goldstein BH: Temporomandibular disorders: a review of current understanding. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999, 88:379–385.PubMedCrossRefGoogle Scholar
  49. 49.
    Major PW, Nebbe B: Use and effectiveness of splint appliance therapy: review of literature. Cranio 1997, 15:159–166.PubMedGoogle Scholar
  50. 50.
    Dao TT, Lavigne GJ: Oral splints? The crutches for temporomandibular disorders and bruxism? Crit Rev Oral Biol Med 1998, 9:345–361.PubMedGoogle Scholar
  51. 51.
    Magnusson T, Syren M: Therapeutic jaw exercises and interocclusal appliance therapy. A comparison between two common treatments of temporomandibular disorders. Swed Dent J 1999, 23:27–37.PubMedGoogle Scholar
  52. 52.
    American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, edn 3 revised. Washington, DC: American Psychiatric Association; 1987.Google Scholar
  53. 53.
    Moss RA, Garret JC, Choido JF: Temporomandibular joint dysfunction and myofascial pain dysfunction syndrome: parameters, etiology and treatment. Psychol Bull 1984, 92:331–346.CrossRefGoogle Scholar
  54. 54.
    Dworkin SF: Behavioral and educational modalities. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997, 83:128–133.PubMedCrossRefGoogle Scholar
  55. 55.
    Carlson CR, Okeson, JP, Falace DA, et al.: Stretch-based relaxation and the reduction of EMG activity among masticatory muscle pain patients. J Craniomandibular Disord 1991, 5:205–212.Google Scholar
  56. 56.
    Carlson CR, Curran SL: Stretch-based relaxation training. Patient Educ Counseling 1994, 23:5–12.Google Scholar
  57. 57.
    Crider AB, Glaros AG: A meta analysis of EMG biofeedback treatment of temporomandibular disorders. J Orofac Pain 1999, 13:29–37. Reviews the extant literature on the use of biofeedback in patients with TMD pain. It provides a quantitative review with estimates of overall effect size for this treatment.PubMedGoogle Scholar
  58. 58.
    Mishra KD, Gatchel RJ, Gardea MA: The relative efficacy of three cognitive-behavioral treatment approaches to temporomandibular disorders. J Behav Med 2000, 23:293–309. Compares three treatments based on the biopsychosocial model: 1) biofeedback, 2) CBT, and 3) combined biofeedback and CBT with a no-treatment control group. All three treatment groups showed significant improvement in pain and functioning and outcomes. The biofeedback group was the most significantly improved compared to the no-treatment group.PubMedCrossRefGoogle Scholar
  59. 59.
    Turk DC, Okifuji A: A cognitive-behavioral approach to pain management. In Textbook of Pain, edn 4. Edited by Wall PD, Melzack R. London: Churchill-Livingstone; 1999:1431–1444.Google Scholar
  60. 60.
    Dworkin SF, Turner JA, Wilson L, et al.: Brief group cognitive-behavioral intervention for temporomandibular disorders. Pain 1994, 59:175–187.PubMedCrossRefGoogle Scholar
  61. 61.
    Morley S, Eccleston C, Williams A: Systematic review and meta analysis of randomized controlled clinical trials of cognitive behavior therapy and behavior therapy for chronic pain in adults, excluding headache. Pain 1999, 80:1–13. This meta-analysis integrates a large number of treatment outcome studies for a range of chronic pain disorders. It provides strong support for the use of CB treatments, many of which integrate physical, behavioral, and cognitive components.PubMedCrossRefGoogle Scholar
  62. 62.
    Turner JA, Romano JM: Cognitive-behavioral therapy for chronic pain. In Bonica’s Management of Pain, edn 3. Edited by Loeser J. Baltimore, MD: Lippincott, Williams & Wilkins; 2001:329–341.Google Scholar
  63. 63.
    Turk DC, Zaki HS, Rudy TE: Effects of intraoral appliance and biofeedback/stress management alone and in combination in treating pain and depression in patients with temporomandibular disorders. J Prosthet Dent 1993, 70:158–164.PubMedCrossRefGoogle Scholar
  64. 64.
    Penzien DB, Holroyd KA: Psychosocial interventions in the management of recurrent headache disorders: description of treatment techniques. Behav Med 1994, 20:64–73.PubMedCrossRefGoogle Scholar
  65. 65.
    Von Korff Mz; Pain management in primary care: an individualized stepped-care approach. In Psychosocial Factors in Pain: Critical Perspectives. Edited by Gatchel RJ, Turk DC. New York: Guilford; 1999:360–373.Google Scholar
  66. 66.
    Carlson CR, Bertrand PM, Ehrlich AD, et al.: Physical selfregulation training for the management of temporomandibular disorders. J Orofac Pain 2001, 15:47–55.PubMedGoogle Scholar
  67. 67.
    Dworkin SF, Huggins KH, Wilson L, et al.: A randomized clinical trial using the Research Diagnostic Criteria for Temporomandibular Joint Disorders Axis II to target clinic cases for a tailored self care TMD treatment program. J Orofac Pain 2001, in press.Google Scholar
  68. 68.
    Rudy TE, Turk DC, Zaki HS, et al.: An empirical taxometric alternative to traditional classification of temporomandibular disorders. Pain 1989, 36:311–320.PubMedCrossRefGoogle Scholar
  69. 69.
    Kerns RD, Turk DC, Rudy TE: The West Haven-Yale Multidimensional Pain Inventory (WHYMPI). Pain 1985, 23:345–356.PubMedCrossRefGoogle Scholar
  70. 70.
    Rudy TE, Turk DC, Kubinski JA, et al.: Differential treatment responses of TMD patients as a function of psychological characteristics. Pain 1995, 61:103–112.PubMedCrossRefGoogle Scholar
  71. 71.
    Stohler CS, Zarb GA: On the management of temporomandibular disorders: a plea for a low-tech, high prudence therapeutic approach. J Orofac Pain 1999, 13:255–261. Provides a data-based rationale for using conservative treatments as a first choice for TMD pain.PubMedGoogle Scholar

Copyright information

© Current Science Inc 2001

Authors and Affiliations

  • Jeffrey J. Sherman
    • 1
  • Dennis C. Turk
    • 2
  1. 1.Department of Oral MedicineUniversity of WashingtonSeattleUSA
  2. 2.Department of AnesthesiologyUniversity of WashingtonSeattleUSA

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