1. Why the pain increase when chewing?

What is Gamma Gain:

Oftentimes, there may be hyperactivity of the gamma motor neurons. This
hyperactivity causes continual tightening of the intrafusal fibers, known as gamma
gain. Gamma gain leads to hypertonicity in the muscle , causing adaptive shortening
of surrounding fascial tissues. These taut bands of fascial tissues lead to
hypersensitive trigger points associated with myofascial pain syndrome (MFPS).
The question of what causes gamma gain is unclear. However, acute injury will result
in muscular spasm and guarding. Also, pain receptors (nociceptors) increase gamma
motor response. Chronic pain, such as that of MFPS is also a result of gamma gain.
The aforementioned hyperactivity of the gamma motor neuron, hypersensitivity to
stretch and subsequent adaptive tissue shortening becomes hypersensitive to stretch.
Stretch of fascial tissue is painful and this results in an increase in gamma motor
activity; a vicious cycle of gamma motor hyperactivity, hypersensitivity,
hypertonicity, adaptive shortening, and pain. The cycle builds from mild, localized
discomfort and will progress to a pain pattern that includes moderate to severe pain
with pain referral.

The Gamma Gain Cycle

For effective treatment of this persistent pain pattern, therapy must focus on breaking
this cycle. Breaking this cycle by blocking gamma gain is the focus of two manual
therapy techniques: myofascial release and straincounterstrain. The positioning for
these techniques decrease gamma motor activity and interrupts the cycle.

Myofascial Release:
Many modalities can be used to treat physically active individuals, and all treatment
plans for myofascial pain should include active therapeutic exercise. None of these
interventions, however, directly address the problem of fascial restrictions and gamma
gain.
Myofascial release techniques, more specifically indirect myofascial release
techniques, place muscle and fascia in positions that remove stress from the tissues.
The application of light, sustained pressure up to the fascial resistance barrier allows
the tissue to relax. The shortened position decreases noxious stimulus from the tissue,
which in turn diminishes activity in gamma motor nerves. Direct techniques attempt
to stretch bound fascia, by applying load through a restrictive barrier. This will
decrease the afferent input from the tissue. Both types of techniques can be used to
treat myofascial pain pattern, however, the primary focus of the indirect technique is
to address gamma gain, by decreasing efferent stimulus.
http://stoneathleticmedicine.com/2013/12/gamma-gain-myofascial-pain-syndrome-andtreatment-using-myofascial-release-and-strain-counterstrain/

2. Why the doctor suggest to take the x-ray and special examination?
Your health care provider usually begins with a thorough physical examination and
medical history, including a review of symptoms. The provider will likely perform a
detailed exam of the affected muscles, including strength and range of motion testing.
He or she will rub the suspected trigger points to see if the muscles respond, or twitch,
and cause pain in a predictable pattern or specific region.
Sometimes blood tests will be performed to look for medical causes of muscle pain,
such as vitamin D deficiency or hypothyroidism.

The type of pain that you may have with myofascial pain syndrome can be similar to the
symptoms of several types of disorders. Accurately determining the correct source of your
pain is critical to successful treatment diagnostic procedures include:

Begins with a thorough clinical evaluation

Including a complete medical history, analysis of your symptoms, and physical

examination

Testing may include x-rays, MRI and/or CT scans, and electro-diagnosis (EMG)
An electromyogram (EMG) is a test that is used to record the electrical activity of
muscles. When muscles are active, they produce an electrical current. This current is
usually proportional to the level of the muscle activity. An EMG is also referred to as
a myogram.

These advanced diagnostic techniques definitively pinpoint the source of pain

3. Treatment of Myofascial Pain Syndrome
Optimal treatment of myofascial pain syndrome can includes patient education, stress
reduction, stretching and exercise, sleep improvement, and medications.
Myofascial pain syndrome resolves with treatment but many patients with myofascial
pain syndrome may continue to have symptoms for years.
Factors that make the condition worse like injury, stress should be avoided.
Underlying depression should be treated and optimal sleep should be restored.
Physical Therapy
Myofascial release techniques, massage, cervical stretch and stabilization are integral
parts of this approach. The primary goal of physical therapy is to restore balance
between muscles working as a functional unit. Postural retraining is crucial.
Trigger Point Injection
One of the most accepted means of treating myofascial pain besides physical therapy
and exercise. Injection is performed most commonly with local anesthetic, although
dry needling is equally effective.
Stretch and spray
This technique is performed using a vapocoolant spray applied to the affected muscle
after it has been placed in passive stretch.
Ischemic Compression

Ischemic compression involves application of sustained pressure on the trigger point.

With muscle in a fully stretched position, press firmly on the trigger point with a
thumb. Gradually increase the pressure as the pain lessens.
Drug Therapy
Analgesics
Non steroidal anti-inflammatory drugs are the drugs of choice for the initial treatment
of myofascial pain. Ibuprofen, Indomethacin, naproxen, diclofenac and ketoprofen are
commonly used drugs.
Opioid analgesics like tramadol can also be used.
Tricyclic Antidepressants
Tricyclic antidepressants like amitriptyline are commonly used for chronic pain. They
also help to treat assocoiated insomnia.
Muscle Relaxants
Cyclobenzaprine, baclofen, carisoprodol, tizanidine are commonly used muscle
relaxants.
Anticonvulsants
Gabapentin has been shown to be effective in treating myofascial and neuropathic
pain.
Drug treatment

Analgesics, non-steroidal anti-inflammatory drugs and/or muscle relaxants.

Antidepressants:
o Tricyclic antidepressants, e.g. starting with a low or moderate bedtime dose
for 2-4 weeks; if helpful, continue for 2-4 months and then taper down to a
low maintenance dose.
o An alternative is a newer antidepressant such as a selective norepinephrine
reuptake inhibitor, e.g. duloxetine.
o Selective serotonin reuptake inhibitor (SSRI) antidepressants have been used,
but some (fluoxetine and paroxetine) may increase bruxism and are not
recommended.

Benzodiazepines have been used, but there is a risk of dependence.

One small case study suggested that tiagabine may be helpful for bruxism.13

4. TMJ Arthroscopy and arthrography ?

Arthroscopy: A surgical technique in which a tube-like instrument is inserted into a joint
to inspect, diagnose, and repair tissues. It is most commonly performed in patients with
diseases of the knees or shoulders.
TMJ arthroscopy is a type of surgery that is performed on the temporomandibular joint
of the jaw. This procedure is most frequently used to treat a medical condition known as
temporomandibular joint disorder after non-surgical treatment options have failed. This is
usually an outpatient procedure, although some doctors may prefer to monitor the patient
overnight in a hospital setting to make sure there are no post-surgical complications.
Recovery time following TMJ arthroscopy is usually about a week, during which time a
special diet may need to be followed. Any questions or concerns about the TMJ
arthroscopy or recovery issues on an individual basis should be discussed with a doctor or
other medical professional.
Temporomandibular joint

Arthroscopy of the temporomandibular joint is sometimes used as either a diagnostic

procedure for symptoms and signs related to these joints, or as a therapeutic measure in
conditions like temporomandibular joint dysfunction. TMJ arthroscopy can be a purely
diagnostic procedure,[9] or it can have its own beneficial effects which may result from
washing out of the joint during the procedure, thought to remove debris and inflammatory
mediators, and may enable a displaced disc to return to its correct position. Arthroscopy is

also used to visualize the inside of the joint during certain surgical procedures involving the
articular disc or the articular surfaces, similar to laparoscopy.[10] Examples include release of
adhesions (e.g., by blunt dissection or with a laser) or release of the disc. [11] Biopsies or disc
reduction can also be carried out during arthroscopy.[9] It is carried out under general
anesthetic.[12]
Arthroscopy is the endoscopic examination of the joint space. It is used for both diagnosis
and treatment. Adhesions and loose bodies are the most common indications and findings for
arthroscopic treatment of the temporomandibular joint. Advancements in techniques have
allowed arthroscopy to be employed in several internal derangement procedures, including
some disc procedures.
Arthrographyjaw movements videotaped with x-rays taken after dye is injected into the
joint (gerakan rahang direkam dengan x-ray diambil setelah bahan pewarna disuntikkan ke
dalam sendi)
Arthrographythe X-ray examination of a joint after injection of a contrast medium into
the joint space
Arthrogram examinations are usually performed with a local anesthetic. The injection is
made under careful aseptic conditions, usually in a combination fluoroscopic-radiographic
examining room that has been carefully prepared in advance. The sterile items required,
particularly the length and gauge of the needles, vary according to the part being examined.
The sterile tray and the nonsterile items should be set up on a conveniently placed instrument
cart or a small two-shelf table.
After aspirating any effusion, the radiologist injects the contrast agent or agents and
manipulates the joint to ensure proper distribution of the contrast material. The examination
is usually performed by fluoroscopy and spot images. Conventional radiographs may be
obtained when special images, such as an axial projection of the shoulder or an
intercondyloid fossa position of the knee, are desired.