An Evidence-Based Treatment of Myofascial Pain and Myofascial Trigger Points in the Maxillofacial Area: A Narrative Review

Myofascial pain (MFP) in the maxillofacial region is a complex condition characterized by localized pain in specific muscles, caused by hypersensitive points known as trigger points. This narrative review examined 29 studies to identify evidence-based best practices for the treatment of this condition, which primarily affects the masseter, temporalis, and medial pterygoid muscles. Research showed that MFP has a higher incidence between 40-50 years of age and is more common in women. The authors conducted a comprehensive search across multiple databases, including Google Scholar, Scopus, Web of Science, and MEDLINE, using terms such as 'myofascial pain syndrome,' 'pain,' and 'orofacial pain.' After a rigorous selection process, 12 studies on pharmacologic interventions and 17 on non-pharmacologic treatments were included.

Pharmacologic interventions demonstrated significant efficacy. Nonsteroidal anti-inflammatory drugs (NSAIDs) proved highly effective in managing inflammatory pain, working through cyclooxygenase inhibition. Tizanidine, a centrally acting alpha-2 agonist, provided significant relief in painful muscle spasms with a dose of 2 mg three times daily. Tricyclic antidepressants, particularly amitriptyline, demonstrated anti-inflammatory and anti-neuropathic properties, with statistically significant pain reduction (p = 0.01) in chronic tension-type headaches.

Botulinum toxin offered a multifaceted approach, promoting increased muscle blood flow and release of endogenous endorphins. Lidocaine, functioning as a sodium channel blocker, stabilized neuronal membranes, with similar efficacy between injection and topical patch application. Among non-pharmacologic interventions, dry needling proved comparable to trigger-point injections for acute cases, inducing a localized twitch response that disrupts motor end plate activity. Behavioral therapy proved valuable considering the psychological factors that influence pain threshold.

Physical modalities such as transcutaneous electrical nerve stimulation (TENS) demonstrated 53.3% efficacy, compared with 93.3% for therapeutic ultrasound. TENS works by increasing endogenous opioids in circulation and improving blood flow. Orofacial myofunctional therapy (OMT) focused on specific exercises to restore stomatognathic function, with significant reductions in painful sensitivity to muscle palpation and improvement in mandibular range of motion. Occlusal splints represented a predominant approach, with various types available from soft splints to rigid stabilizing splints, although their exact mechanisms remain under investigation.

Low-level laser therapy (LLLT) demonstrated moderate efficacy in pain relief in temporomandibular MFP. The methodologic quality of the studies varied, with assessment by JBI criteria revealing that studies scoring between 50-79% had moderate risk of bias, while those with 80-100% had low risk. Limitations include lack of a rigorous systematic approach in study selection and absence of comprehensive comparisons of treatment duration across modalities. The authors concluded that a combined approach integrating pharmacologic and non-pharmacologic strategies offers more effective holistic management of trigger points.

For acute cases, efficacy was demonstrated for analgesics, muscle relaxants, dry needling, and TENS. Future research should focus on robust systematic reviews and meta-analyses to establish more definitive evidence-based protocols for MFP management, especially considering the individual variability in response to treatments and the need for therapeutic personalization.