Dr. Shapira's Chicago Headache Blog

IMPROVEMENT IN QUALITY OF LIFE WITH TMD TREATMENT HAS RECENTLY BEEN PUBLISHED. THIS STUDY USED EVIDENCED BASED ARTICLES FROM Medline and Cochrane Library databases. This severely limited the number of studies considered and eliminates publications of exciting clinical work and case reports. This type of search tends toward bias toward drug therapy.

The study showed almost universal improvement in the quality of life with TMD treatment. The twelve papers reviewed showed that the more symptoms and the worse the condition was to begin with the greater the improvement in the quality of life. These results are unmatched in most of medicine where even a 50% improverment is touted. Men and women appeared to improve equally.

The study concluded that: "The reviewed studies convincingly demonstrated that OHRQoL (quality of life) was negatively affected among TMD patients. this coincides with other known materials including Shimshak et al who published in Cranio Journal a 300% increase in medical spending in all medical fields.

An excellent article on how TMD affects the quality of life can be fond in Sleep and Health Journal at:
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor Neuromuscular dentistry has begun to exhibit exponential growth as measured facts are replacing opinions.


AN EXCITING NEW ARTICLE ON IMActa Odontol Scand. 2010 Mar;68(2):80-5.
Temporomandibular disorders and oral health-related quality of life. A systematic review.
Dahlström L, Carlsson GE.

Research Center, Public Dental Service, Clinic of Odontology, Göteborg, Sweden. lars.dahlstrom@vgregion.se
OBJECTIVE: Oral health-related quality of life (OHRQoL) is considered an important aspect of different oral conditions. It has also gained increased attention in temporomandibular disorders (TMDs) in recent years. The purpose of this study was to systematically review the literature on OHRQoL and TMDs. MATERIAL AND METHODS: A systematic search of the dental literature was performed using the Medline and Cochrane Library databases, supplemented by a hand search. Various combinations of search terms related to OHRQoL and TMDs were used. Among numerous titles found in Medline, abstracts and eventually full papers of potential interest were reviewed. Twelve papers fulfilled the inclusion criteria and were included in the review. RESULTS: Most studies used the Oral Health Impact Profile, an instrument with good psychometric properties, for evaluation. All articles described a substantial impact on OHRQoL in TMD patients. Only a small proportion of all patients, a few percent, reported no impact at all. The difference between men and women was small and not significant. The impact appeared to be more pronounced in patients with more signs and symptoms. The perceived impact of pain on OHRQoL seems to be substantial. Two studies found that the impact increased with age among TMD patients. CONCLUSIONS: The reviewed studies convincingly demonstrated that OHRQoL was negatively affected among TMD patients.

PMID: 20141363 [PubMed - in process]

Labels: CGRP neuromuscular dentistry, improving quality of life, improving quality TMD, neuromuscular dentistry tmd, quality of life, TMD neuromuscular dentistry

A RANDOMIZED CONTROLLED TRIAL (see abstract below) OF OSTEOPATHIC TREATMENT AND CONVENTIONAL TMD TREATMENT REVEALED THEY WERE APPROXIMATELY EQUAL WITH THE OSTEOPATHIC GROUP USING LESS MEDICATION.

THIS STUDY IS IMPORTANT FOR TWO REASONS. FIRST, IT SHOWS THAT THERE IS AN INTIMATE CONNECTION BETWEEN THE NECK AND THE JAW. FOR THE PURPOSES OF A STUDY IT MAKES SENSE TO DO A RANDOMIZED TRIAL. IF THE HEALTH AND WELLNESS OF THE PATIENT IS OUR FIRST CONCERN COMBINING TREATMENTS IS THE MOST EFFECTIVE COURSE.

THE SECOND POINT IS THAT CONVENTIONAL TMD THERAPY NEEDS IMPROVEMENT. NEUROMUSCULAR DENTISTRY CAN PROVIDE VASTLY SUPERIOR RESULTS THAN CONVENTIONAL TMD THERAPY. THE STUDY PUBLISHED IN CRANIO JOURNAL BY DR BARRY COOPER SHOWED THAT NEUROMUSCULAR DENTISTRY WAS "OVERWHELMINGLY SUCCESSFUL" IN TREATING THESE PROBLEMS.

I have found that combining Neuromuscular Dental Treatment with Atlas/Orthogonal, NUCCA, or Cranial-sacral therapy can improve treatment as well.

The majority of patients with TMJ disorders also have sleep disorders. Treating both the sleep and daytime problems can drastically improve patients results.

"Osteopathic manual therapy versus conventional conservative therapy in the treatment of temporomandibular disorders: A randomized controlled trial

A.M. Cucciaa, b, , , C. Caradonnaa, b, V. Annunziatab and D. Caradonnaa, b
a Department of Dental Sciences “G. Messina”, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy
b School of Specialization in Orthodontics, University of Palermo, Via del Vespro 129, 90128 Palermo, Italy
Received 10 April 2009; revised 1 August 2009; accepted 12 August 2009. Available online 20 September 2009.
Summary
Objective
Temporomandibular disorders (TMD) is a term reflecting chronic, painful, craniofacial conditions usually of unclear etiology with impaired jaw function. The effect of osteopathic manual therapy (OMT) in patients with TMD is largely unknown, and its use in such patients is controversial. Nevertheless, empiric evidence suggests that OMT might be effective in alleviating symptoms. A randomized controlled clinical trial of efficacy was performed to test this hypothesis.
Methods
We performed a randomized, controlled trial that involved adult patients who had TMD. Patients were randomly divided into two groups: an OMT group (25 patients, 12 males and 13 females, age 40.6 ± 11.03) and a conventional conservative therapy (CCT) group (25 patients, 10 males and 15 females, age 38.4 ± 15.33).
At the first visit (T0), at the end of treatment (after six months, T1) and two months after the end of treatment (T2), all patients were subjected to clinical evaluation. Assessments were performed by subjective pain intensity (visual analogue pain scale, VAS), clinical evaluation (Temporomandibular index) and measurements of the range of maximal mouth opening and lateral movement of the head around its axis.
Results
Patients in both groups improved during the six months. The OMT group required significantly less medication (non-steroidal medication and muscle relaxants) (P < 0.001).
Conclusions
The two therapeutic modalities had similar clinical results in patients with TMD, even if the use of medication was greater in CCT group. Our findings suggest that OMT is a valid option for the treatment of TMD.
Keywords: OMT; Physical therapy; Stomatognathic system; Occlusal splint; Masticatory muscle"

Labels: neuromuscular dentistry, OMT; Physical therapy; Stomatognathic system; Occlusal splint; Masticatory muscle

An interesting article in Science Daily (http://www.sciencedaily.com/releases/2010/03/100324094644.htm) discusses an new method to estimate the risk of falls. Neuromuscular Dentistry can reduce the risks of falls. It has been used to treat vertigo and dizziness as well as other middle ear dysfunctions related to the TM Joint (TMJ).

THE RISK OF FALLING IS A MAJOR CONCERN FOR OLDER ADULTS BUT APPARANTLY IS ALSO A PROBLEM AT ALL AGES. Neuromuscular Dentistry can lower the risk of dangerous falls. Can Neuromuscular Dentistry save medicare. According to the article 40% of all senior hospital admissions are related to falls and over a third of seniors over age 65 fall annually. If neuromuscular dental appliances could reduce fallsin seniors by only 10% it would save medicare tens of billions of dollars in hospital and rehabilitation costs and prevent the rapid deterioration to the quality of seniors lives often associated with falls.

Neuromuscular Dentistry is based on the work of Dr Barney Jankelson who applied physiological measurements to dentistry. His work has resulted in help for patients with migraines, tension headaches and TMJ disorders (http://www.ihateheadaches.org). It is also extremely effective in helping balance and postural issues. The New Orleans Saints utilized Neuromuscular Dentistry to help win the Superbowl. The PPM Mouthguard or Pure Power Mouthguard was developed by Neuromuscular Dentist Anil Makkar to improve physical performance including balance strengthand flexibility. A Rutger's Study confirmed these effects.

The Pure Power Mouthpiece mproves balance in athletes but can it do the same for seniors or other patients with balance problems? If the number of falls could be reduced the savings to medicare would be enormous. An explanation of the science behind Neuromuscular Dentistry can be found in Sleep and Health Journal at http://www.sleepandhealth.com/neuromuscular-dentistry

ICCMO, the International College of CranioMandibular Orthopedics is the professional association that consists of medical professional (pimarily dentists) who are trained in Neuromuscular Dentistry and in correcting the physiology of the stomatognathic and trigeminal systems. Neuromuscular Dentistry primarily addresses the health of the Trigeminal Nerve that accounts for over 50% of the total input to the brain. The trigemono-vascular system is a primary agentof almost all chronic headaches including Migraines,Chronic Daily Headaches, Tension-Type Headaches, Episodic Tension-Type Headaches, Sinus Pain, TMD, Retroorbital Headaches, Morning headaches, Facial Pain and other common pain syndromes.

The NIH has numerous studies on alternative medicine techniques. I believe that the NIH should evaluate the Rutger's study and use it as a template for a study addressing balance and avoidance of falls universally but especially in seniors. Forward head posture ncreases problems with balance and can be addressed by orthopedic correction of mandibular position utilizing diagnostic neuromuscular orthotics.

Another recent article in Gait and Posture "showed that voluntary teeth clenching contributed to stabilization of the postural stance perturbed transiently by electrical stimulation. We concluded that voluntary teeth clenching plays an important role in rapid postural adaptation to the anterior-posterior perturbation in the upright position." This study was an experimental electrical impulse to disrupt posture and voluntary closure of the teeth restored posture.. This entire field relates back to the work of Sherrington and the righting reflex.

Gait Posture. 2010 Jan;31(1):122-5. Epub 2009 Oct 30.
Influence of voluntary teeth clenching on the stabilization of postural stance disturbed by electrical stimulation of unilateral lower limb.

Fujino S, Takahashi T, Ueno T.
Department of Sports Medicine and Dentistry, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8549, Japan. sfujino.spmd@tmd.ac.jp
Studies on the relationship between dental occlusion and body balance have suggested that occlusion status contributes to the maintenance of postural balance. However, little has been reported about the effects of voluntary teeth clenching on the stabilization of postural stance in novel environments. In the present study we investigated whether teeth clenching influenced adaptation to the perturbation introduced by electrical stimulation of a unilateral lower limb. Subjects (12 adults) stood on a force plate, from which motion data were obtained in the horizontal plane with and without voluntary teeth clenching and were instructed to maintain the position throughout the experiment. We evoked a novel environment by supramaximal percutaneous electrical stimulation of the common peroneal nerve. Electromyograms (EMG) were recorded from the masseter and the peroneus longus (PL) muscles with bipolar surface cup electrodes. When the disturbed postural stance was generated by electrical stimulation, the maximum reaction force in the anterior-posterior (A/P) direction with teeth clenching (CL) was significantly smaller than that without voluntary teeth clenching (control; CO) (p<0.05) and the peak time of the ground reaction force/body mass (GRF/BM) in the A/P direction occurred earlier in the CL condition than CO (p<0.05). There were no significant differences in the peak-to-peak amplitude of GRF/BM and the peak time of GRF/BM, in the M/L direction under both CL and CO conditions. Thus, the present study showed that voluntary teeth clenching contributed to stabilization of the postural stance perturbed transiently by electrical stimulation. We concluded that voluntary teeth clenching plays an important role in rapid postural adaptation to the anterior-posterior perturbation in the upright position. Copyright 2009. Published by Elsevier B.V.

Labels: balance, CGRP neuromuscular dentistry, falls hospital admissions, pure power mouthguard, risk of falls, Rutgers, saving medicare

DANGERS OF WISDOM TOOTH REMOVAL: PARESTHESIA & TMJ DAMAGE ARE THE PRIMARY CONCERNS OF WHEN REMOVING MANDIBULAR THIRD MOLARS

THIS IS A REPRINT OF A SLEEP AND HEALTH JOURNAL BLOG. I THINK IT IS IMPORTANT TO UNDERSTAND THAT THERE MAY BE A RELATION BETWEEN CHRONIC HEADACHES, MIGRAINES AND TMJ DISORDERS AND REMOVAL OF WISDOM TEETH. I BELIEVE THERE IS A BETTER ALTERNATIVE.

The removal of mandibular third molars frequently results in associated morbidities, the most concern is about paresthesia or permanent numbness from nerve damage. I have also frequently seen patients with TMJ disorders (TMD) such as joint locking, clicking or pain after removal of wisdom teeth. Chronic headaches and migraines may occur as a secondary result of trauma and TMD. My letter to the editor of the Journal of the American Dental Association (JADA) concerning these issues is reproduced below. I thought this issue was important enough to post regardless of whether it is published in JADA. Patients who have had chronic pain, headaches and TM Joint disorders after third molar surgery can frequently find relief thru Neuromuscular Dentistry. There are articles on neuromuscular dentistry in Sleep and Health Journal and an article about Temporomandibular disorders Suffer No More: Dealing with the great imposter. The website http://www.ihateheadaches.org has extensive information about eliminating and alleviating migraines, chronic daily headaches and episodic tension type headaches. RSD or CRPS can be a secondary long term pain condition related to damage caused in extracting wisdom teeth.

My letter to JADA editor follows.
"I would like to thank the authors of “Cortical integrity of the inferior alveolar canal as a predictor or paresthesia after third molar extraction”. Their use of cone beam radiology to predict which patients have the greatest risk of paresthesia should help clinicians be aware of which extractions are most likely to cause paresthesia due to loss of cortical integrity of the canal. Cone beam 3-D imaging will hopefully reduce the incidence of future paresthesias.

This study reported on 179 participants, average age of 23.6 and 4.2% developed paresthesia in spite of use of cone beam radiology. I believe these statistics clearly point out it is time to re-evaluate the primitive approach that is still considered standard protocol for managing third molars.

A more rational approach would be the utilization of early prophylactic minimally invasive dental surgery to remove the developing tooth bud prior to calcification thereby reducing the risk of paresthesia to zero. There are numerous other advantages to early prophylactic removal of mandibular third molars. Ideally the removal should be planned between the ages of 8 and 11 (prior to eruption of second molars.) the uncalcified tooth bud is readily accessible for easy removal. There is less than one millimeter of bone covering the tooth bud which is located just beneath the crest of the ridge. The major advantage to early removal is that it will eliminate 100% of paresthesia cases as well as reduce overall post-operative morbidity associated with third molar removal. The procedure will require only a small amount of infiltration anaesthesia and will have virtually no post-op complications. It will eliminate periodontal defects caused by the presence or removal of third molar, eliminate and decay problems on the distal of the second molar from the wisdom teeth and will prevent damage to the TM Joints and lingual nerve during surgery.

Stem cells are currently being studied and collected from extracted wisdom teeth and from deciduous teeth upon their removal. Stem cells are found in the pulp and periodontal ligament tissues. These are sites that have stem cells but they are of marginal value compared to stem cells that can be harvested from the developing tooth bud.

The developing tooth bud offers an excellent source of high quality stem cells at a much earlier stage of development. The stem cells that will eventually form enamel, dentin, pulpal tissue, periodontal ligament tissues, blood vessels and nervous tissue including at least 29 distinct types of nervous receptors found in the periodontal ligament. This tissue has already been shown in Japanese studies to be capable of developing into liver and cardiac tissues.

The minimally invasive surgical approach to removal of tooth buds and collection of stem cells from the bud and from the surrounding bone will only take about 2 -3 minutes per site after infiltration anesthesia. Because the nerves are not yet connected to the CNS there is only minimal need for anesthesia to the overlying mucosa.

I currently have method and device patents on instruments to allow prophylactic minimally invasive removal of the developing tooth bud and collection of stem cells from the developing tooth bud and surrounding tissue eliminating future problems associated with mandibular third molars.

Ira L Shapira DDS, DABDSM, DAAPM, FICCMO"

COMMENT:
EARLY PROPHYLACTIC MINIMALLY INVASIVE REMOVAL OF THIRD MOLARS IS POSSIBLE IS NOT CURRENTLY A ROUTINE PROCEDURE. HOPEFULLY, IN THE FUTURE THIS WILL BECOME A NORMAL PROTOCOL. THE COLLECTION OF STEM CELLS FOR PERSONAL USAGE IS GROWING IN POPULARITY. I WOULD PERSONALLY RECOMMEND THAT EVERYONE SAVE UMBILICAL CORD BLOOD AT BRTH IF POSSIBLE. THIS IS AN ALTERNATIVE FOR PARENTS WHO WERE UNABLE TO SAVE CORD BLOOD AND A VALUABLE ADDITION FOR PARENTS WHO HAVE SAVED CORD BLOOD.

IT IS ALSO AN EXCELLENT PUBLIC SERVICE IF PATIENTS CAN BANK CELLS FOR PERSONAL USE FROM ONE TOOTH BUD AND PROVIDE THE OTHER FOR PUBLIC USE SIMILAR TO CORD BLOOD BANKS.

Labels: NUMBNESS AFTER WISDOM TOOTH EXTRACTION STEM CELLS FROM TOOTH BUD STEM CELLS WISDOM TEETH TMJ PROBLEMS AFTER WISDOM TOOTH REMOVAL W

Patients missing one or more permanent molars are more prone to headaches and TMJ disorders. Missing just a single first molar has been shown to double the resk of headaches, sinus pain and /TMJ disorders. When the molars are missing there can be drastic increases in headaches and TMJ disorders. Patients with loss of vertical dimension are more prone to morning headaches, sleep apnea and migraines.

Dental Implants are frerquently used to replace missing teeth when treating headaches and migraines associated with TMJ diorders.

Labels: Dental Implant, dental implants, facial pain TMJ, implant dentistry, Migraines, missing teeth, neuromuscular dentistry, neuromuscular dentistry tmd

A new article in the Journal of Musculoskeletal Pain by Michael Sorrell, MD of Tufts University showed excellent results in treating Migraine utilizing trigger point injections and physical therapy with supervised home stretching. The examination of the myofascial trigger points is a step rarely done in working up migraine patients,The majority of patients had received previous diagnosis of migraine and had undergone unsuccessful drug treatment. These patients were unaware that their pain could be referred from muscles until the examination of the muscles revealed the referred pain.

The examination did not include all of the the masticatory muscles but did include masseter and temporalis muscles,the sternocleidomastoid muscle,the trapezius muscle, the corrugater supercilius, the semispinalis, splenius cevicus and capitus muscles, as well as the suboccipitalis and levator scapulae muscles. If muscle palpation examination reproduced the headache the patients were included in the trial.

This study only included patients with chronic migraine and migraine without aura whose pain could be reproduced from muscle examination. A subgroup of 11 patients with Migraine with aura (5 of 11 patients migraine symptoms reproduced on examination) was also included in the study. Those patients did remarkably well with 68% mean improvement in those receiving physical therapy and home stretching compared to 5% improvement in the group not utilizing physical medicine. Over 88% of the study group reported over 50% improvment.

This is an important article primarily because it is from a neurology group treating migraines. It is well known that tension type headaches respond to physical medicine and treatment of myofascial trigger point. Migraines are usually very responsive to physical medicine as well. The field of Neuromuscular Dentistry actively focuses on the elimination trigger through use of TENS, TP injections, Spray and Stretch and other techniques as well. More importantly use of neuromuscular trigger points prevents the formation of new trigger points.

The examination in the above article ignored many of the masticatory muscles known to creat migraine like symptoms.

There is also an important concept of myofascial triggers serving as a trigger for migraines. Removal of these triggers can eliminate future migraines.

I have frequently seen migraine patients achieve complete relief thru a combination of a neuromuscular diagnostic orthotic and physical medicine modalities. I have seen other patient who have greatly reduced frequency of migraine but when a migraine does occur medication is still necessary due to severity. This is common with hormonal headaches and migraines. I will have a patient with severe diaily migraines that are eliminated but the patient qwill still have a tension type headache or migraine at ovulation or prior to Menses.

These are patients who I believe we have relieved the myofascial components of their pain but the hormonal triggers remain. The headaches that are then present are less severe. Other patients may only get the aura when presented with triggers but no pain. I do believe that evaluation and elimination of myofascial triggers is important for all migraine patients but in some patients the myofacial trigger points are a secondary result of the migraine pain rather that a primary cause of migraine. It is still important to eliminate these secondary trigger points so the do not increase and become a primary problem.

Labels: common migraine, migraine cure, migraines with aura, MPD, myofascial pain, neuromuscular dentistry, tension-type headaches, trigger point injections

I frequently hear stories of patients who have severe circumstances that result from relatively non-invasive treatment. An example below is the letter I just received.

A temporary crown placed in the middle of January 2010 caused horrible face pain, eye pressure stabbing ear pains, refered tooth pains, migraines on opposite side of normal, facial numbness and neck spasms. Extreme pain for about 7 weeks. Pain is still persistant but now at tolerable levels.Two trips to endodontic clinic sent me to Neuralogist who did MRI and MRA and diagnosed me with Neurological disorder triggered by dental work. It is time to put on crown permanently. Neurologist says next event could trigger more intense an longer lasting pain. Is there any dentist in Wichita, Ks. who might cause less trauma with this procedure? Neurologist next wants to do a sleep study to see if improper night oxygen levels could be causing overactive nervous system and delayed healing. Would love to hear your comments! Thank you for your consideration, B.A.

The question is what set off this problem? Usually there were existing problems already present and the new crown was the proverbial "strw that broke the camels back". It is possible that the crown was too big or changed the bite but it is also possible that merely having the mouth open for an extended appointment was enough to create the problem. Regardless, once the problem is in full glory it often takes more than just correcting the crown to fix the problem.

The basic principles of neuromuscular dentistry is to idealize position of the jaw, the jaw muscles, the jaw joint and the bite to a position of minimal adaptation for healing. Neurological problems related to the trigeminal nerve will frequently self correct.

Labels: Extreme pain, facial numbness, MRA, MRI, neck spasms, Neurological disorder, trigger pain

When chronic or acute ear pain occurs an evaluation by an otolaryngologist or ENT is a good way to begin treatment. The exception to this rule is when movements of the lower jaw cause the ear pain or the motion of the lower jaw is limited. This is a sign of a TMJ disorder. If it happens suddenly it may be the sign of an acute close-lock of the TM Joint and a dentist with experience in treating temporomandibular disorders is a must. Neuromuscular Dentistry is extremely effective in treating chronic haeadaches, migraines, Tension Headaches and TMD but when an acute close lock occurs time is of the essence to prevent permanent damage.

Many neuromuscular dentists know how to manage the chronic pain aspect of TMD but are less sure of handling an acute disk dislocation.

The wrong treatment is to not attempt to reduce the dislocation, taking anti-inflamatories or pain meds without attempting to reduce the dislocation. The longer the disk is out the more likely there will be permanent damage or internal derangement of the TMJ.

A trip to the emergency room is usually non-productive or may even create additional damage if they try to force the jaw open.

A simple method to reduce a close-lock it to stimulate a strong gag reflex which will sometimes reduce the dislocation. It is then necessary to stabilize the joint with an orthotic.

Labels: atypical migraine, ear pain, facial pain TMJ, migraine neuromuscular dentistry, neuromuscular dentistry, otalgia, temporomandibular joint, TM Joint, TMD Migraine