(See also Overview of Temporomandibular Disorders.)
This condition is the most common temporomandibular disorder (1). It is more common in women than men and occurs more commonly in younger people (2).
In the affected muscle, both pain and trigger points (which cause referred pain) may result from parafunctional behavior such as bruxism (clenching or grinding of the teeth and/or bracing or thrusting of the mandible). Bruxism is regarded as 2 distinct entities: sleep or awake bruxism, which have different etiologies. Bruxism can be defined as occurring while asleep or awake. Sleep bruxism is rhythmic or non rhythmic masticatory muscle activity during sleep and awake bruxism is characterized by sustained or repetitive tooth contact. (3).
Temporomandibular myofascial pain syndrome is not limited to the muscles of mastication. It can occur anywhere in the body, most commonly involving muscles in the neck, shoulders, and back.
References
1. Manfredini D, Arveda N, Guarda-Nardini L, et al. Distribution of diagnoses in a population of patients with temporomandibular disorders. Oral Surg Oral Med Oral Pathol Oral Radiol. 2012;114(5):e35-e41. doi:10.1016/j.oooo.2012.03.023
2. Janal MN, Raphael KG, Nayak S, Klausner J. Prevalence of myofascial temporomandibular disorder in US community women. J Oral Rehabil. 2008;35(11):801-809. doi:10.1111/j.1365-2842.2008.01854.x
3. Lobbezoo F, Ahlberg J, Raphael KG, et al. International consensus on the assessment of bruxism: Report of a work in progress. J Oral Rehabil. 2018;45(11):837-844. doi:10.1111/joor.12663
Symptoms and Signs of Temporomandibular Myofascial Pain Syndrome
Symptoms include pain and tenderness of the masticatory muscles and often pain and limitation of jaw excursion. Both sleep bruxism and sleep-disordered breathing (such as obstructive sleep apnea and upper airway resistance syndrome) are associated with headache that is more severe on awakening and gradually subsides during the day. Such pain must be distinguished from the pain caused by giant cell arteritis, which can result in visual loss if not diagnosed and treated promptly. Awake symptoms, including jaw muscle fatigue, jaw pain, and headaches, usually worsen if parafunctional behavior continues throughout the day.
The jaw deviates to the affected side when the mouth opens but usually not as suddenly or always at the same point of opening as it does with internal temporomandibular joint derangement. Sometimes, the examiner can exert gentle pressure on the lower anterior teeth which can stretch the involved muscles and thereby assist the patient in opening the mouth another 1 to 3 mm beyond unaided maximum opening.
Diagnosis of Temporomandibular Myofascial Pain Syndrome
Primarily history and physical examination
The diagnosis is typically based on the patient's history and physical examination. A simple test may aid the diagnosis: 2 or 3 tongue blades are placed between the rearmost molars on each side, and the patient is asked to close the mouth gently (1, 2, 3). This clenching procedure will activate the masticatory muscles. If the masticatory muscles are the source of the pain then the patient will indicate this procedure intensifies their pain while pointing to the area of the pain. Radiographs usually do not aid in diagnosis, but can exclude arthritis or other pathologies. If giant cell arteritis is suspected, C-reactive protein and erythrocyte sedimentation rate (ESR) should be measured.
Although temporomandibular myofascial pain syndrome can cause sleep disturbances, polysomnography should be performed if sleep-disordered breathing is suspected.
Diagnosis references
1. Schiffman E, Ohrbach R, Truelove E, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache 28(1):6-27, 2014. doi: 10.11607/jop.1151
2. Peck C, Goulet J-P, Lobbezoo F, et al. Expanding the taxonomy of the diagnostic criteria for temporomandibular disorders. J Oral Rehabil 41(1):2-23, 2014. doi: 10.1111/joor.12132
3. International Classification of Orofacial Pain, 1st edition (ICOP).Cephalalgia 40(2):129-221, 2020. doi: 10.1177/0333102419893823
Treatment of Temporomandibular Myofascial Pain Syndrome
Self-management therapies
Analgesics
Oral appliances
Possibly temporary use of a benzodiazepine or cyclobenzaprine at bedtimePossibly temporary use of a benzodiazepine or cyclobenzaprine at bedtime
Trigger point injections and other physical and behavioral therapy modalities
The patient must learn to avoid parafunctional behavior (eg, clenching the jaw, grinding the teeth, bracing or thrusting of the mandible) when awake. Hard-to-chew foods and chewing gum should be avoided. Physical therapy, biofeedback to encourage relaxation, and counseling help some patients (1, 2).
Analgesics, such as NSAIDs or acetaminophen, individually or in combination, are usually effective. Because the condition is chronic, opioids should not be used, except briefly for acute exacerbations. In some cases of chronic pain, antidepressant medication is useful (Analgesics, such as NSAIDs or acetaminophen, individually or in combination, are usually effective. Because the condition is chronic, opioids should not be used, except briefly for acute exacerbations. In some cases of chronic pain, antidepressant medication is useful (3).
An oral appliance from a dentist can keep teeth from contacting each other and thereby reduce the damage caused by bruxism. Over-the-counter heat-moldable (boil and bite) mouth guards are available from many sporting goods stores or pharmacies; however, these types of devices should be used briefly and only as short-term diagnostic tools and only for short-term relief. Because these mouth guards may cause unwanted tooth movement or create a paradoxical increase in muscle activity, oral appliances should be fabricated, fitted, and adjusted by a dentist.
Low doses of a benzodiazepine at bedtime are often effective for acute exacerbations and temporary relief of symptoms (4, 5). Cyclobenzaprine may facilitate muscle relaxation. However, in patients with ). Cyclobenzaprine may facilitate muscle relaxation. However, in patients withassociated sleep disorders, such as sleep apnea, benzodiazepines and muscle relaxants should be used with caution because they can aggravate these conditions.
Physical modalities include trigger point injections, transcutaneous electric nerve stimulation (TENS), and “spray and stretch,” in which the jaw is stretched open after the skin over the painful area has been chilled with ice or sprayed with a skin refrigerant, such as ethyl chloride. Botulinum toxin may be used successfully to relieve muscle spasm. (TENS), and “spray and stretch,” in which the jaw is stretched open after the skin over the painful area has been chilled with ice or sprayed with a skin refrigerant, such as ethyl chloride. Botulinum toxin may be used successfully to relieve muscle spasm.
Most patients, even if untreated, customarily have diminished or cessation of significant symptoms within 6 to 12 months.
Treatment references
1. Story WP, Durham J, Al-Baghdadi M, Steele J, et al. Self-management in temporomandibular disorders: a systematic review of behavioural components. J Oral Rehabil. 2016;43(10):759-770. doi:10.1111/joor.12422
2. Durham J, Al-Baghdadi M, Baad-Hansen L, et al. Self-management programmes in temporomandibular disorders: results from an international Delphi process. J Oral Rehabil. 2016;43(12):929-936. doi:10.1111/joor.12448
3. Dei T, Galloway K, Fagundes NCF, et al. Beyond Depression: The Role of Antidepressants in Managing Chronic Temporomandibular Disorders. A Systematic Review. J Oral Rehabil. 2025;52(6):923-936. doi:10.1111/joor.13971
4. Klasser GD, Romero Reyes M, eds. Orofacial Pain: Guidelines for Assessment, Diagnosis, and Management. 7th Ed. Quintessence; 2023.
5. List T, Axelsson S. Management of TMD: evidence from systematic reviews and meta-analyses. J Oral Rehabil. 2010;37(6):430-451. doi:10.1111/j.1365-2842.2010.02089.x
Key Points
Temporomandibular myofascial pain syndrome is a more common cause of temporomandibular pain than temporomandibular joint derangement.
Tension, fatigue, and (rarely) spasm of the masticatory muscles may result from parafunctional behavior (eg, bruxism).
Patients have pain and tenderness of the masticatory muscles, painful limitation of jaw excursion, and sometimes headache.
Use of oral appliances, benzodiazepines or muscle relaxant during sleep may help, along with nonopioid analgesics; behavioral modalities and physical therapy are sometimes appropriate.
Drugs Mentioned In This Article
