James R. Fricton
Eric L. Schiffman
Myalgia and arthralgia refer to muscle and joint pain disorders, respectively. When these disorders involve the masticatory muscles, the temporomandibular joint (TMJ), or both, they are collectively called temporomandibular disorders (TMDs).1 TMD pain is typically felt in the jaw, temple, ear, and face. The hallmark of TMD pain is that it is altered by function including eating and/or by para-function including oral habits. The most common signs include pain in the muscles and/or TMJs upon palpation, pain or limitation with jaw range of motion (ROM), irregular jaw movements, or TMJ noises. The purpose of this chapter is to present the most common disorders that can cause masticatory myalgia and arthralgia and to discuss their management.
Proper physical diagnosis related to the patient’s pain complaint(s) and all relevant contributing factors will facilitate successful management.1 Medical disorders and other orofacial disorders need to be considered in the differential diagnosis of TMDs. Comorbid conditions such as dental pulpitis, rheumatoid arthritis, fibromyalgia, tension-type headache, and migraine headache can present with similar or overlapping pain complaints that can complicate the diagnostic process (see also chapters 19,20, and 25).2,3
Masticatory myalgia is characterized as a dull persistent ache overlying the jaw and temple muscles with occasional referral to other structures such as head, neck, ear, and teeth. Symptoms can also include a restricted opening, fatigue, and stiffness. Signs include tenderness of the muscles with limited ROM. Common myalgias include myofascial pain (regional and referred pain associated with localized areas of tenderness called trigger points), masticatory tension-type headache (pain in the temporalis muscles area, with replication of the headache on muscle palpation or stretching), myositis (pain with generalized muscle tenderness), muscle spasm (acute pain with limited ROM), and contracture4 (long-standing limited ROM).
TMJ arthralgia is characterized by joint tenderness and preauricular pain with occasional referral to the periauricular, upper neck, and temporal regions.1 Pain is related to inflammatory and/or mechanical factors. If inflammation is significantly present, the diagnosis is arthritis, also referred to as capsulitis or synovitis. The inflammatory process may also be due to a local disorder such as disc displacement or a systemic disease, including rheumatoid arthritis. Mechanically related pain may be associated with local disorders including disc displacement with reduction with intermittent locking, disc displacement without reduction with limited opening, TMJ hypermobility, or osteoarthritis (see chapter 1).5,6 A rheumatology consultation is indicated if signs and symptoms such as swelling, warmth, redness, and involvement of other joints are present.
The decision to initiate treatment for the conditions is based on the presence of pain and/or restricted jaw movement that affects use of the jaw and quality of life. The treatment goals include the following1:
1. Reduce or eliminate pain
2. Restore comfortable jaw function and quality of life
3. Reduce the need for future health services
There is no simple approach to be used on all patients. Patients with myalgia and arthralgia often have multiple comorbid conditions and/or contributing factors. As other chapters have noted (see chapters 17 to 19), patients have individual beliefs, experiences, behaviors, and emotions related to their pain; each of these factors can influence treatment outcome. Cost, previous unsuccessful treatments, preferences, pain severity, and doctorpatient relationships can also influence a patient’s motivation to follow recommendations. A well-designed treatment plan that is tailored to the patient’s unique characteristics and focuses on treating the diagnostic condition while addressing relevant contributing factors will best achieve these goals. If any identifiable cause such as pain from third molar impaction, an uncomfortably high restoration, or recent trauma to the jaw is present, this should be managed first.
The treatment options for TMDs are also consistent with medical management of muscloskeletal disorders in other parts of the body (Box 22-1). While there is some evidence from randomized clinical trials to support the use of several of the management strategies outlined in this chapter, management of patients with TMDs still remains both an art and a science.
|Box 22-1 Management options for TMDs|
|Patient education and self-care|
|Physical medicine therapy|
|Intraoral splints and dental treatment|
|Complementary and alternative therapies|
|Referral or team management|
Patient education and self-care
Most myalgias and arthralgias can improve over time if they are allowed to heal by resting the affected muscles and joints. Consequently, initial treatment for TMDs should be reversible and directed at self-care to promote normal healing. A key to successful management involves empowering the patient through education about the problem and ensuring compliance with self-care.7,8 Self-care is designed to rest the jaw, reduce overuse, and encourage normal function (Box 22-2).
|Box 22-2 Self-care approaches for masticatory myalgia and arthralgia|
|Apply moist heat or cold to the sore joint or muscles. Heat or ice applications used up to four times per day can reduce joint or muscle pain and relax the muscles. For heat, microwave a wet towel for approximately 1 minute or until towel is warm. Wrap this moist warm towel around a hot-water bottle or heated gel pack to keep it warm longer. Apply it to the affected area for 15 to 20 minutes. For cold,/>|