Treatment of temporomandibular joint syndrome with biofeedback training

Nonsurgical Management of Pediatric Temporomandibular Joint Dysfunction

Temporomandibular disorders (TMD) are a subgroup of craniofacial pain problems involving the temporomandibular joint (TMJ), masticatory muscles, and associated head and neck musculoskeletal structures. These disorders are subclassified into TMJ articular disorders and masticatory muscle disorders. Patients with TMD most commonly present with pain, restricted or asymmetric mandibular motion, and TMJ sounds during mandibular movements. The prevalence tends to increase with age. Management of TMJ articular disorders consists of a combination of patient education, home-care plan, biobehavioral therapy, physical therapy, orthotic jaw appliance therapy, pharmacotherapy, and/or surgery. The goal is to increase function, reduce pain, and improve quality of life.

Update on burning mouth syndrome: overview and patient management

Burning Mouth Syndrome (BMS) is a chronic pain syndrome that mainly affects middle-aged/old women with hormonal changes or psychological disorders. This condition is probably of multifactorial origin, often idiopathic, and its etiopathogenesis remains largely enigmatic. The present paper discusses several aspects of BMS, updates current knowledge, and provides guidelines for patient management. There is no consensus on the diagnosis and classification of BMS. The etiopathogenesis seems to be complex and in a large number of patients probably involves interactions among local, systemic, and/or psychogenic factors. In the remaining cases, new interesting associations have recently emerged between BMS and either peripheral nerve damage or dopaminergic system disorders, emphasizing the neuropathic background in BMS. Based on these recent data, we have introduced the concepts of "primary" (idiopathic) and "secondary" (resulting from identified precipitating factors) BMS, since this allows for a more systematic approach to patient management. The latter starts with a differential diagnosis based on the exclusion of both other orofacial chronic pain conditions and painful oral diseases exhibiting muco-sal lesions. However, the occurrence of overlapping/overwhelming oral mucosal pathologies, such as infections, may cause difficulties in the diagnosis ("complicated BMS"). BMS treatment is still unsatisfactory, and there is no definitive cure. As a result, a multidisciplinary approach is required to bring the condition under better control. Importantly, BMS patients should be offered regular follow-up during the symptomatic periods and psychological support for alleviating the psychogenic component of the pain. More research is necessary to confirm the association between BMS and systemic disorders, as well as to investigate possible pathogenic mechanisms involving potential nerve damage. If this goal is to be achieved, a uniform definition of BMS and strict criteria for its classification are mandatory.

The relative efficacy of three cognitive-behavioral treatment approaches to temporomandibular disorders

The purpose of this study was to evaluate the relative efficacy of different biopsychosocial treatment conditions on patients with chronic temporomandibular disorder. Ninety-four patients with chronic temporomandibular disorder were assigned to either a biofeedback treatment group, a cognitive-behavioral skills training (CBST) treatment group, a combined (combination of biofeedback/CBST) treatment group, or a no-treatment control group. Pain scores were analyzed pretreatment and posttreatment to determine group and within-subjects treatment effects. Results demonstrated that, in terms of a self-reported pain score, all three treatment groups had significantly decreased pain scores from pretreatment to posttreatment, while the no-treatment group did not. Moreover, patients in the biofeedback group were the most significantly improved compared to the no-treatment group. Finally, participants in the three treatment groups displayed significant improvement in mood states.

[Integrated and frequency spectra of the electromyograms in patients with temporomandibular symptoms]

With the aid of bipolar surface electrodes, the electromyographic activity of the anterior temporal and the superficial masseter muscles were recorded bilaterally and evaluated by counting the integrated potentials and mean power frequency using Fourier's analysis. A comparison between 17 patients with myofacial pain dysfunction (average age 21.3 years) and a group of 20 controls (average age 20.5 years) revealed a significantly greater activity in patients with pain syndrome, while no significant inter-group difference in mean power frequency was seen. The differences in the level of activity between the right and left sides in the control group were significantly smaller than in patients with pain dysfunction. An investigation of measures aimed at reducing the right/left asymmetry in a further 14 patients with pain dysfunction revealed the practice of "maximum occlusion with feedback" to be the most effective measure.

Devices for the diagnosis and treatment of temporomandibular disorders. Part III: Thermography, ultrasound, electrical stimulation, and electromyographic biofeedback

This last article in the three-part series on devices for the diagnosis and treatment of temporomandibular disorders (TMD) compared the claimed diagnostic usefulness of thermography with the present scientific evidence. In a similar manner, the therapeutic efficacy of ultrasound, electrical stimulation, and electromyographic biofeedback was also reviewed. This evaluation concluded that the application of thermography to the diagnosis of TMD is limited by variations within and among subjects and by intrinsic problems with controls of the test environment. It also concluded that evidence that therapeutic ultrasound alone is useful for the treatment of TMD is lacking, that positive clinical results of electrical stimulation may not be due to specific therapeutic effects, and that it is doubtful that the use of electrical stimulation devices can produce a position of the mandible that has any diagnostic or therapeutic significance. There is evidence, however, that relaxation training, assisted by EMG biofeedback, can reduce daytime muscle activity.

Monitoring behavioural stress control using a craniomandibular index

This study was concerned with the practical value of relaxation training in helping an individual reduce anxiety and its physical manifestations. Twenty-five subjects learned and practised transcendental meditation for a period of three months. Subjects were clinically examined before and after meditation training, and a craniomandibular index (CMI) was used to objectively assess criteria pertaining to mandibular function. Baseline and outcome CMI scores were compared for the group and shown to be significantly different. Deep relaxation achieved through transcendental meditation alleviated intramuscular tension and fatigue, promoting balanced, co-ordinated muscle function.

Electromyographic biofeedback and rest position training of masticatory muscles in myofascial pain-dysfunction patients

Twenty-four women outpatients with myofascial pain-dysfunction were divided into three groups of eight. All received bilateral masseter electromyographic biofeedback training. One group received biofeedback only; one group received additional instructions and modeling to place their jaw in the "rest" position; and one group was given a prosthetic guide that spaced the incisors 6.8 mm apart. Two 15-minute training sessions were conducted at a 1-week interval, with posttreatment assessment 2 weeks later. The instruction and prosthesis groups obtained significantly greater electromyographic reductions in masseter activity and increases in mandibular range of motion compared with the biofeedback-only group. Subjects with pain obtained a significant reduction in therapist and self-report pain ratings. The results suggest that short-term biofeedback treatment may be meaningfully augmented by procedures that place the mandible in the rest position.

Stress as a factor in muscle and temporomandibular joint pain

Stress-induced muscle hyperactivity has been proposed as a major aetiological factor in the production of pain in the muscles of mastication and the temporomandibular joints. In the present study, a total of fifty-two patients with joint or muscle pain were evaluated for stress with the Derogatis Stress Profile (DSP). The muscle pain group (n = 24) had higher clinician ratings of psychological factors, stress and chronicity. The muscle-pain group also had higher Environmental Stress scores on the DSP, more intense pain, and more activity impairment than the joint-pain group (n = 28). The results of multiple regression analysis suggest an association between pain, depression, and impairment of activity in the muscle-pain group but not in the joint-pain group. The overall results further suggest that muscle pain develops at 'normal' levels of stress.

Diagnosis and treatment of myofacial pain-dysfunction (MPD) syndrome

The successful management of patients with MPD syndrome is dependent on establishing an accurate diagnosis and using proper therapy based on an understanding 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 psychophysiologic disease originating in the muscles of mastication and not an organic disease arising in the temporomandibular 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, 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, it is important that the clinician does not succumb to an unproven fad or use of an irreversible procedure that will not achieve better results.

Stress-induced muscular activity in mandibular dysfunction: effects of biofeedback training

Surface electromyographic (EMG) recordings from the left and right masseteric areas during physical and psychological induced stress were obtained from 20 patients with mandibular dysfunction and 20 healthy controls. Integrated electromyographic activity was not significantly different for the two sides but was higher for patients than for controls during both stress and relaxation. Anxiety level, as measured with the Taylor Manifest Anxiety Scale, was higher for patients. Biofeedback treatment for the patients resulted in significantly reduced signs and symptoms of mandibular dysfunction. When the test procedures were repeated, the controls had not changed in their electromyographic responses during stress, whereas the patients showed a significant decrease in this respect. The results obtained are discussed in terms of a systems-oriented etiological concept.

Effects of biofeedback training on tonic masticatory neck reflex: a case report

Biofeedback training to reduce muscle tension lowered not only the spontaneous activity but also the tonic neck reflex in the jaw closing muscles. Tolperisone-HCl, which may inhibit the gamma system, inhibited the tonic masticatory neck reflex, but did not reduce the patient's spontaneous activity of the jaw closing muscles in this case. Biofeedback training may be considered to reduce the gamma as well as alpha motor systems.

Clinical and electromyographic effects of biofeedback training in mandibular dysfunction

Twenty patients with mandibular dysfunction, 10 acute and 10 chronic, were trained with electromyographic biofeedback from either m. masseter or m. frontalis area. The electromyographic activity in both muscle areas were recorded during six training sessions. The mean electromyographic activity decreased significantly within the sessions for both muscle areas, progressively more often for the m. masseter area. The activity did not decrease significantly between sessions for any muscle area. The clinical and subjective symptoms of mandibular dysfunction improved significantly after the training. No differences, electromyographically or clinically, among acute, chronic, m. masseter area, or m. frontalis area feedback patients could be observed. No correlation between decrease in electromyographic activity and symptoms could be established. Since a simplistic neuromuscular learning model for biofeedback training gains little support from these results, alternative views are discussed.

Temporomandibular joint disfunction syndrome and myofascial pain dysfunction syndrome: a critical review

Temporomandibular joint (TMJ) dysfunction syndrome and myofascial pain dysfunction (MPD) syndrome have been primarily viewed as dental problems and have only recently received close attention by psychologists. The literature reviewed in the present paper reveals that a substantial portion of the population is affected by these disorders. There is, however, a great deal of confusion that exists in relation to the aetiology and treatment of these syndromes. In an attempt to clarify the current understanding of these disorders, the present review first presents a discussion of the symptoms which comprise each of these syndromes and the proposed physiological mechanisms associated with each symptom. Next, the aetiological theories for each of these syndromes are reviewed and critically evaluated. Treatments which have been derived from the theoretical models are then discussed. Finally, methodological considerations involving classification, assessment and treatment issues are presented and future research needs are outlined.

Assessment and treatment of stress in myofascial pain-dysfunction syndrome: a model for analysis

Myofascial pain dysfunction (MPD) syndrome has received widespread attention in the dental and psychological literature. The present paper considers issues concerning a stress-related muscular hyperactivity theory of MPD syndrome. A review of the empirical evidence as well as methodological problems evident in these studies has been noted. In addition, definition aspects of stress and a conceptual model of stress in clinical use is presented. A functional analysis of the problem components will help determine a proper treatment protocol for patients suffering from stress-related myofascial pain. A discussion of the conceptual model for assessment and treatment purposes is presented and its implications for future research noted.

The comparative efficacy of relaxation training and masseter EMG feedback in the treatment of TMJ dysfunction

The present series of single case studies was designed to evaluate the comparative efficacy of masseter EMG feedback with progressive relaxation training in the treatment of TMJ dysfunction. Study 1 employed a multiple baseline design across the symptoms of jaw pain, jaw tension and shoulder pain in a patient with chronic TMJ problems. The results indicated that relaxation training was the treatment responsible for improvements in subjective ratings of jaw pain and tension, whereas masseter EMG feedback provided little additional benefit. Trapezius EMG feedback was necessary to provide improvements in ratings of shoulder pain. Study 2 consisted of four single case designs in which masseter EMG feedback and relaxation training were compared with four TMJ patients. Results indicated that relaxation produced clear improvements in pain and tension ratings for two patients, a combination of EMG feedback and relaxation training resulted in slight improvements in one patient, and neither treatment procedure was effective for the final patient. The possibility of wide-scale application of relaxation training with TMJ patients and the need for further controlled research of masseter EMG feedback were discussed.

Myofascial pain-dysfunction syndrome: a psychobiological perspective

Myofascial pain-dysfunction (MPD) syndrome is a muscle-contraction headache-like pain of the face. In the past this has also been called temporomandibular joint syndrome. This syndrome is thought to be, in part, a stress-related pain. This paper discusses and evaluates the following topics: (1) patient characteristics, (2) etiological hypotheses, (3) experimental models of the syndrome, (4) psychological characteristics of the patients, (5) psychophysiological characteristics of the patients, and (6) relaxation therapies. Future research is also discussed.

Etiology and treatment of occlusal pathosis and associated facial pain

The treatment of occlusal pathosis and associated facial pain is a difficult and complex problem. The interaction of two etiologic factors, occlusal interferences and psychologic stress, results in parafunctional activity. The most important prerequisite to selection of a treatment method is an understanding of the etiology of the problem. What dentistry needs is a mechanism by which the major etiologic factor of parafunctional activity can be identified for each patient. Treatment can then be directed toward the reduction or elimination of that factor. When treatment is directed toward the major cause of the problem, the likelihood of success will increase greatly. Continued research on this problem will yield new insights and means for the accurate determination of the etiology of parafunctional activity for each patient.

Myofascial pain of the temporomandibular joint: a review of the behavioral-relaxation therapies

This paper reviews the behavioral-relaxation treatments of myofascial pain-dysfunction syndrome. The evidence indicates that this pain (located around the oral cavity) is due to muscle hyperactivity, most commonly of the lateral pterygoids. Research concerning relaxation techniques (i.e. progressive muscle relaxation and electromyographic feedback) has indicated the following: (a) in analogue research, normal healthy controls can learn to relax their muscles of mastication profoundly even during stress, and (b) in case reports, relaxation treatments are helpful clinical interventions, especially for pain patients who are not depressed, and who have not had the pain for more than a few years. Well controlled research is the next, essential step.

Biofeedback therapy for headache and other pain: an evaluative review

A survey of the literature is presented in two areas of biofeedback treatment for headache--muscle contraction and migraine--and a variety of miscellaneous pain syndromes. The studies done to date are characterized largely by lack of proper no-treatment or placebo control groups, by confounding biofeedback with a variety of other strategies, or by sample sizes too small to afford any reasonable conclusions about efficacy. There is some evidence that biofeedback works better for muscle contraction headache than false feedback, but it also appears that biofeedback is no more effective than relaxation training. The application of biofeedback to migraine or other pain syndromes remains of unproven value. Investigators seldom attempt to relate empirically their interventions to hypothetical models of pain mechanisms. The potential influence of extraneous factors linked to the therapeutic situation is pervasive in these studies, but examination of their specific roles in symptom reduction is largely missing. Some variables are listed which need to be examined and which may contribute to the alleviation of pain with much less expenditure of clinical resources than that demanded by biofeedback. Perhaps the main contribution of biofeedback has been to highlight such extraneous variables in the pain treatment setting.

Biofeedback and relaxation training in the treatment of psychophysiological disorders: or are the machines really necessary?

The literature on the use of biofeedback and various forms of relaxation training in the treatment of psychophysiological disorders was reviewed; special attention was devoted to studies in which biofeedback and some form of relaxation training were compared. Based on this review, we conclude that there is no consistent advantage for one form of treatment over the other with any psychophysiological disorder for which a comparison has been made, e.g., essential hypertension, migraine headaches, premature ventricular contractions, tension headaches, temporomandibular joint pain, asthma, primary dysmenorrhea, and functional diarrhea. For other disorders in which no comparisons have been made (e.g., Raynaud's disease, sinus tachycardia, peptic uclers, and fecal incontinence) biofeedback seems to be a very promising treatment modality.

Electromyographic biofeedback: behavioral treatment of neuromuscular disorders

Electromyographic biofeedback is becoming widely used to help patients regain voluntary control of specific muscles affected by neuromuscular disorders. Electromyographic feedback training has been employed in the rehabilitation of patients affected by poliomyelitis, cerebrovascular accident, torticollis, nerve injury, temporomandibular joint syndrome, bruxism, and other disorders. While EMG biofeedback appears to be a promising treatment technique, the research literature on its effectiveness consists mainly of uncontrolled case reports and clinical trials. It is concluded that new studies with more sophisticated design and more careful control are needed to demonstrate that EMG biofeedback makes a unique contribution to the treatment of neuromuscular disorders. Research is needed to identify relevant patients characteristics predictive of success, specify appropriate muscle groups for the treatment of particular disorders, determine how feedback can be most efficiently combined with more conventional techniques in achieving a therapeutic effect, and establish meaningful criteria of success in the treatment of neuromuscular disorders.

Frustration and temporomandibular joint pain

The significance of frustration as a cause of temporomandibular joint pain is investigated through the use of bilateral electromyographic recording. Interpretation of both parametric and nonparametric data indicates the lack of relationship. The need for careful controls and the problems of psychologizing are discussed.

Biofeedback in the treatment of long-term temporomandibular joint pain: an outcome study

Eleven patients with long-term pain related to the temporomandibular joint (TMJ) were trained in tension awareness and relaxation using feedback of muscle tension level in the masseter through a digital display. At a follow-up examination 4-15 months after the termination of treatment, 8 of the 11 patients were totally symptom-free or significantly better; 1 patient was slightly better, and there was no effect for 2 patients. Possible reasons for failure and sex differences are discussed.