Scientific Dental Journal

Case Report

The Addition of Pharmacological Treatment to Physiotherapy in

Pain Reduction of TMD-myalgia Patients

1 2
Carolina Marpaung , Hasti Parvaneh
1Department of Prosthodontics, Faculty of Dentistry, Trisakti University – Indonesia
2Special Care Center, Alkmaar Hospital, Alkmaar – The Netherlands
‘Corresponding Author: Carolina Marpaung, Faculty of Dentistry, Trisakti University – Indonesia.
Email: carolina@trisakti.ac.id
Received date: October 27, 2017. Accepted date: December 14, 2017. Published date: January 25, 2018.
Copyright: ©2018 Marpaung C, Parvaneh H. This is an open access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any
medium provided the original author and sources are credited.

ABSTRACT

Background: Myalgia is the most common cause of Temporomandibular Disorders (TMDs) pain, which has a dull and
mild character. In some patients with high somatization, it can present itself as severe pain, which can complicate the
treatment. Additional pharmacological treatment may thus be needed. Case Report: Two female patients came with
similar symptoms but different pain intensities. The first patient had a high intensity of pain, which became severe during
examination. The second patient had more complaints but showed typical symptoms of myalgia. Both received
physiotherapy sessions, but for the first patient, we added analgesics to help the patient endure physiotherapy.
Conclusion: Additional pharmacological treatments, especially analgesics, can be used in helping myalgia patients with
high somatization to undergo physiotherapy.

Keywords : myalgia, pharmacology, temporomandibular disorders, temporomandibular joint, treatment

Background
Temporomandibular disorders (TMD) are a group
of conditions affecting the masticatory muscles, the
temporomandibular joints (TMJ), or both. Pain, functional
limitation, and joint sounds are the cardinal signs for
which patients seek care. 1 Myalgia is the most common
cause of pain in patients with Temporomandibular
disorders (TMD). It presents itself as dull, mild, remitting,
self-limiting, and fluctuating pain.1 A report from a TMD
specialty clinic showed that 55% of their patients met the
criteria of having chronic myofascial pain or myalgia.2
Physiotherapy is the treatment of choice for
myofascial pain treatment, because it relieves
musculoskeletal pain, restores normal function by
coordinating muscle activity, and promotes the repair and
regeneration of tissue.3 The use of pharmacological
treatments in accompanying physiotherapy is often used,
though there is no guidance on when and how to deliver
the mode of treatment.4 This case report describes two
cases of patients with myofascial pain complaint who
underwent physical therapy with and without the addition
of pharmacological treatment.

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Case Report 1
Male patient of 40 years of age complained of clicking
sound with sharp pain on both TMJs. Pain was felt as sharp
following clicking sound, and there was also tense feeling
in the cheek area and around the ears especially after every
meal. Patient scored his pain as 8 on VAS scale. Patient
was afraid to move his jaw due to the pain. Patient did not
have any systemic complaints. During examination,
palpation on the masseter and palpation area provoked his
pain complaint (Fig. 1). There was a limitation on maximal
mouth opening (28 mm), and patient refused to open wider
as he felt a severe pain around the cheek area. Clicking
was detected on both joints on both mouth opening and
closing movement. The diagnosis of this case was myalgia
with myogenous limited mouth opening and anterior disc
displacement with reduction on both joints. The treatment
approach was divided into two parts, which are (1)
counselling on the etiology of pain and clicking sound, and
(2) physical therapy which consisted of massage and
mobilization therapy. Patient was instructed to take
analgesics on the day of the first appointment of physical
therapy. The additional medication was also given on the
second appointment of physical therapy as patient was still
afraid of pain on jaw movement. After the third
appointment, patient could do the physical therapy on his
own which increased his mouth opening to 40 mm without
feeling any pain. Patient was no longer disturbed by his
joint sound.
Figure 1. Palpation was done on masseter area according to Diagnostic Criteria
of Temporomandibula (DC/TMD) protocol
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Case Report 2
Female of 40 years of age came with a blocked feeling
on mouth opening and pain around right cheek area. Pain
started around 5 years ago on the right ear, and felt like a
sharp pain (VAS scale 2) which increased in intensity on
chewing and talking. Patient also complained of
intermittent blockage on jaw movement which started
around 1 year ago. Patient did not have any systemic
complaints. Clinical examination revealed painless mouth
opening of 29 mm, but patient could open until 45 mm
when instructed. Palpation on the right masseter provoked
her pain complaint (VAS scale 4). Palpation on the right
TMJ did not cause any pain, but crepitus sound was
detected during opening and closing jaw movement. The
diagnosis of this case was myalgia with myogenous limited
mouth opening and a possibility of arthrosis on the right
TMJ. The treatment approach was divided into two parts,
which are (1) counselling on the etiology of pain and
movement limitation, and (2) physical therapy which
consisted of massage and mobilization therapy. Patient was
not given any medication on all of her physical therapy
appointments. After two physical therapy sessions, patient
could already open until 40 mm, and her pain was
decreased (VAS scale 2). Patient was instructed to come
every 6 months to evaluate her right joint condition.
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Discussion especially in physiotherapy where pain is expected to be

provoked during certain movements.
Other medications can be used, though it is not
This report discussed about two patients with the
commonly practiced in cases such as the two presented in
same pain diagnosis but received different treatment. The
this case report. For example, muscle relaxants affect
first patient was given additional medication before
skeletal muscle function and are used to decrease muscle
underwent his physiotherapy appointments, while the
tone. One of the medications, Cyclobenzaprine, has been
other was not given any. The exercises which are
used widely in fibromyalgia and tension-type headache
commonly included in myofascial physiotherapy are
treatment.1 The use of muscle relaxant in combination
muscle massage, muscle stretching, gentle isometric
with physiotherapy was, however, lacking evidence. 8
tension exercises against resistance, guided opening and
Other medication, Benzodiazepines, possess sedative,
closing movements, correction of body posture, and
hypnotic, anxiolytic, anticonvulsant, analgesic, muscle
relaxation techniques.5,6 Based on a clinical study, 85% of
relaxant, and amnesic actions, which are useful in chronic
myofascial pain patients no longer experienced pain and
myofascial patients with a high psychological component
60% had improved mouth function in 6-month follow-up
and/or sleep problems.9,10
after physiotherapy.4 However pharma-cological
A study by De Nucci et al. on the efficacy of
treatment is still recommended for initial use in
Triazolam in TMD patients’ pain management showed
myofascial pain treatment, especially in combination with
that there is a significant improvement in sleep quality
physiotherapy.4
and alterations in patients’ sleep architecture. 9
Medications that are widely used are analgesics, non-
Nevertheless, they did not find any improvement in
steroid anti-inflammatory drugs (NSAIDs), muscle
patients’ pain complaint as measured by muscle palpation
relaxants, benzodiazepines, and low-dose antidepressants.
with an algometer, in scales for sensory intensity and the
Questions then arise whether medications add value to the
affective component of pain, or in daily pain diaries. The
overall success of pain management by means of
study also recommended the use of benzodiazepines for
physiotherapy and what the rationale is for giving such
myofascial pain patients to be restricted to 2 to 4 weeks,
medications. In many chronic pain cases, patients will
due to many side effects, dependence risk, and withdrawal
either be prescribed analgesics or have already been
syndrome. In the early years, antidepressants were chosen
taking them. Both non-opioid analgesics and NSAIDs act
because they were thought to relieve the depression
by inhibiting prostaglandin synthesis and they are
component of chronic pain. Although it is well known that
effective in reducing pain and tension feeling
relieving depression is likely to decrease pain, some
accompanying chronic pain patients.7 NSAIDs are only
antidepressants appear to have analgesic properties of its
given if inflammation is the dominant component in the
clinical finding. own.7,11,12 Both benzodiazepines and anti-depressants are
not commonly used in combination with physical therapy
Since analgesics are only prophylactic drugs, they
and there are no studies which observe the combination
have to be accompanied with a more definite treatment
efficacy.
such as physiotherapy. In fact, many combine both
approaches, as to increase the patient’s adaptation and
adherence to the physiotherapy treatment. Clinical Conclusion
reasoning to give additional analgesics in combination
with physiotherapy in this case basically depends on There is not a single study that directly observes the
patients’ condition. The first patient in this case report efficacy of additional pharmacological therapy to
complained of high intensity of pain (VAS Scale 8), physiotherapy in chronic myofascial pain cases. Most of
although on examination it revealed that it was pain of the medications were used when physiotherapy was not
myogenous origin.1 This may indicate that patient had a treatment option of pain management. They were also
high somatization which can complicate treatments, used in a short term and mainly as a prophylactic

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treatment. However, analgesics are often used in the initial
phase of physiotherapy to help patient adapting to the
exercise.
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