Use of Trigger Point Injections in the Management of Myofascial Pain in Patients With Temporomandibular Disorders

Myofascial pain is prominent throughout the general population, with an overall prevalence reported in the literature ranging from 20% to 95%.¹ In the United States, myofascial pain is estimated to affect almost 44 million people.² In the craniofacial region, masticatory myofascial pain–based disorders account for nearly half of all temporomandibular joint disorder (TMD) patients.³

One of the earliest descriptions of this condition was by Dr. Janet Travell, who defined myofascial pain as pain characterized by the presence of myofascial trigger points.⁴ A myofascial trigger point is defined as a palpable, irritable area in a muscle that is painful upon palpation.⁵ The pain response is familiar to the patient, and can also refer to and travel throughout other affected areas.⁶ Additionally, trigger points may exhibit localized twitch responses upon palpation.⁷ Diagnosing myofascial pain in the head and neck involves a thorough examination and palpation of the affected muscles; patients often describe pain, tightness, tension, diminished range of motion, and traveling of sensations.⁷

Trigger Point Injection Therapy

Effective treatment for myofascial pain is multimodal and often includes behavioral, pharmacologic, and/or physical therapy and injection or other needle-based modalities. Physical therapy–based treatment involves massage, rest, ice, heat, and postural or movement-based training. Needle-dependent options include neurotoxin injections, acupuncture, dry needling, and trigger point injections (TPIs).⁸

While there are many variations of TPI therapy, the basic steps include the identification of hyper irritable spots within a muscle, insertion of a small-gauge needle, and delivery of local anesthetic into the identified trigger points.⁹ Alternatives to local anesthetic include saline, steroids, or combinations of these.⁹ Often, patients may describe a crunching or popping sensation at the site of the needle insertion in identified muscles.¹⁰ Common risks associated with TPIs in the head and neck include pain at the site of the injection, localized bleeding, transient partial palsy of the facial nerve, and post-injection muscle soreness. Although rare, injections in the trapezius and sternocleidomastoid muscles can result in pneumothorax.¹¹

Absolute contraindications to TPI therapy include systemic or localized infection, allergy to injection solution, and patient refusal. Relative contraindications include coagulopathy, high anxiety, poorly controlled psychiatric disorders, and complicated anatomy.¹⁰ According to the American Society of Regional Anesthesia and Pain Medicine, in regard to anticoagulation guidelines, TPIs are low risk.¹¹

Dry needling, while similar to but not a form of TPI therapy, involves inserting a thin needle into the identified trigger points. As with TPIs, patient-reported crunching and crackling as well as observed localized twitch responses are common with dry needling.¹² Dry needling differs from TPIs in that it involves repeatedly inserting the needle into the affected muscle tissue with small variations in direction and does not include the injection of a substance.¹²

This article describes a patient who was experiencing long-standing head and neck myofascial pain, which in turn was impacting various aspects of her life and precluding her from being able to receive adequate dental care. After multiple rounds of TPI therapy, the authors were able to reduce her pain, decrease interference from pain, and improve her temporomandibular joint (TMJ) range of motion. These improvements enabled her to address long-standing unmet dental needs.

Clinical Presentation

A 69-year-old woman presented to the University of Washington School of Dentistry Oral Medicine Clinical Services clinic with a chief concern of limited mouth opening. Previously diagnosed with obstructive sleep apnea (OSA), the patient was unable to tolerate continuous positive airway pressure (CPAP) therapy. She was interested in a mandibular advancement device as an alternative treatment, but due to the limited mouth opening had been unable to proceed with fabrication of the oral sleep appliance. The limited mouth opening also had prevented her from undergoing routine dental treatment for about the previous 3 years. She had been referred to multiple clinics and seen by five different dentists who were unable to address her restorative and surgical needs or fabricate the oral sleep appliance. Past successful dental appointments required the use of general anesthesia but not without complications related to her airway anatomy.

At the patient’s initial visit, in addition to the limited opening, she reported severe pain in her head, neck, and masseters with only minimal alleviation provided by physical therapy and massage. Furthermore, because of her inability to open her mouth adequately to perform oral hygiene, she reported multiple areas of tooth decay. Her recent pain levels averaged 7/10, with 4/10 interference with enjoyment of life and general activity (pain, enjoyment, general activity [PEG] scale).¹³ She reported being in severe emotional distress due to pain impacting her daily activities and expressed frustration with having seen multiple providers without experiencing any appreciable improvement. Unmanaged OSA, she said, severely impacted her sleep and energy levels.

Her medical history included congenital fusion at C2/C3 vertebrae, which reportedly was improperly treated when she was a child. This resulted in atrophy of muscles, and because of the congenital fusion, otolaryngologists observed that she had oral cavity and neck architecture that was averse to CPAP and that intubation would be more complex than usual.

Upon examination, the patient’s maximum interincisal opening without pain was 33 mm. In addition, her maximum opening with pain was also 33 mm, with pain elicited bilaterally in the masseters. Furthermore, there was familiar pain to palpation bilaterally involving the sternocleidomastoid, posterior neck, occipitalis, trapezius, temporalis, and masseter muscles with referral patterns throughout the craniofacial region. The authors’ preliminary diagnosis was myofascial pain with referral. Given her lack of response to past therapy, trigger point injections were recommended along with tizanidine 2 mg at bedtime. All trigger points were identified and injected with less than 0.05 mL 3% plain mepivacaine per site.

After 10 minutes, the patient reported relaxation of her jaw and a decrease in overall pain and tightness, especially when opening and closing. Pain drawings shown in Figure 1 and Figure 2 outline her pain distribution pre- and post-injection; post TPIs, there was significant alleviation of her symptoms.

The authors continued to see the patient at 4- to 6-week intervals over the course of 10 months, providing additional TPIs as indicated. Overall, the patient continued to exhibit a significant decrease in general pain and discomfort to the point where she was able to have a dental implant explanted under local anesthesia, and she began to undergo routine dental treatment to address her restorative needs. She demonstrated a modest increase in maximum opening without pain (5 mm increase) and was able to tolerate fabrication and use of a mandibular advancement device. She subsequently reported that her symptoms associated with OSA improved significantly and that she no longer required additional sleep during the day. Her pain decreased to an average of 3–4/10, and her interference with enjoyment of life and general activity both decreased to 1/10 at her final visit (Figure 3).¹³

Discussion

Head and neck myofascial pain demonstrates widespread prevalence in the general population and is commonly seen in patients with headaches, TMD, and post–whiplash syndrome.¹ Predisposing factors are numerous and include postural and parafunctional habits, psychological distress, and trauma.¹³ Furthermore, Slade et al demonstrated that patients with a higher frequency of somatic symptoms had a significant increase in the incidence rate of TMD.¹⁴ Also, patients with poorer overall systemic health, with either comorbid disease or social habits such as smoking, showed an increase in TMD incidence.¹⁴ Sleep impairment is also noted to be a strong predictor of pain, and patients with TMD were associated with a deterioration in sleep quality.¹⁴ Myofascial pain can significantly impact activities of daily living and reduce quality of life.¹³ Anxiety and depression are often comorbidities, and patients with myofascial pain are more anxious and depressed than patients with other subtypes of TMD.¹⁵

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) is a validated protocol dentists and dental specialists can utilize to identify and diagnose pain related to TMD to help provide timely, effective care for patients.¹⁶ Simple, minimally invasive procedures such as TPIs can significantly alleviate muscle-based pain and offer the opportunity to decrease suffering in patients who are impacted in various aspects of their life. TPIs are thought to work by mechanically relaxing the taut bands of muscle, which in turn helps improve perfusion and restore adenosine triphosphate, lengthening muscle fibers and removing metabolic waste in the muscle.¹⁷ TPIs, however, should be performed as part of a multimodal approach to care that incorporates behavioral interventions, physical therapy, massage, and possible pharmacological interventions.²

The patient described in this case was also undergoing physical therapy and massage, which provided transient relief. Adjuncts that the authors advised included prescription of a topical ethyl chloride spray for use on affected muscles as needed and a trial of 2 mg tizanidine, which appeared to help her symptoms.

A review conducted in 2022 summarizing the management of temporomandibular disorders demonstrated the importance of conservative interventions as a first-line therapeutic approach.¹⁸ In addition, treating patients based on physical diagnoses (axis 1) with complementary emphasis on addressing psychosocial factors (axis 2) such as depression, anxiety, and stress is important in patients with chronic musculoskeletal pain; as such, establishing a supportive therapeutic alliance and ensuring patients feel heard and validated can help improve pain outcomes.^17,18 It is the authors’ hope that outlining this case will enable providers to better understand, and be open to incorporating, TPIs as a therapeutic option in their armamentarium to help address myogenic TMD.

Conclusion

Myofascial pain can profoundly impact a patient’s quality of life and underscores the importance of a multidisciplinary, patient-centered approach to treatment. Through consistent trigger point injection therapy, combined with physical therapy and pharmacologic support, the patient in this case experienced measurable improvements in function and pain levels. This case report demonstrates that with appropriate diagnosis and targeted, minimally invasive treatments, patients with myofascial pain can regain function and access necessary dental and medical interventions.

ABOUT THE AUTHORS

Kevin Chung, DDS, MSD
Acting Assistant Professor, Department of Oral Medicine, School of Dentistry, University of Washington, Seattle, Washington; Attending Faculty, Oral Medicine Service, Fred Hutch Cancer Center, Seattle, Washington

Nicholas Sotak, DMD, MSD
Assistant Professor, Department of Oral Medicine, School of Dentistry, University of Washington, Seattle, Washington

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