Dr. Shapira's Chicago Headache Blog

The article "emporomandibular dysfunction: an often overlooked cause of chronic headaches" published in Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8 recommends evaluating patients with chronic daily headaches for TMJ disorders. This interesting article looks at 25 years of Pub Med searches of the keywords " temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache". The article concludes "The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities."

The article is directed to ENT and allergy physicians and notes "Allergists and immunologists are frequently called on to evaluate patients with chronic headaches and facial pain. TMD is known to cause recurrent facial discomfort and headaches. Many individuals with the disorder present with headache or facial discomfort as their only chief complaint. They mistakenly think it is a "sinus" headache. Nearly 10 million Americans are affected by the disorder, and early studies estimate that TMD pain is the cause of chronic headaches in 14% to 26% of individuals with recurrent headaches"

NEUROMUSCULAR DENTISTRY CAN DIAGNOSE AND TREAT CHRONIC DAILY HEADACHES BY UTILIZING A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC. A DIAGNOSTIC ORTHOTIC , WHEN SUCCESSFUL IN ELIMINATING PAIN NOT ONLY IS THE FIRST STEP OF TREATING OR CURING THE DISORDER BUT ALSO GUIDES THE PRACTITIONER IN THE BEST MEANS OF TREATMENT.

ACCORDING TO THIS ARTICLE "As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy"

This is not uncommon. TMJ or TMD is frequently called "THE GREAT IMPOSTER" because patients are frequently given multiple courses of antibiotics to treat non-existent infections, given migraine medications for headaches that are myofascial in orgin or subjected to multiple CAT scans and MRI's that are essentially normal. Please see the Sleep and Health Article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" to leatn more about how neuromuscular dentistry can help eliminate, prevent or alleviate migraines, tension-type headaches, chronic daily headaches, facial pain or sinus pain and/or pressure. These are all frequently symptoms of TMJ disorders.

Additional information on Neuromuscular Dentistry can be found in "Neuromuscular Dentistry" an article originally published by the American Equilibration Society that has been republished in Sleep and Health Journal @ http://www.sleepandhealth.com/neuromuscular-dentistry

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PubMed abstract below
Ann Allergy Asthma Immunol. 2007 Oct;99(4):314-8.
Temporomandibular dysfunction: an often overlooked cause of chronic headaches.
Lupoli TA, Lockey RF.

Division of Allergy and Immunology, Department of Internal Medicine, University of South Florida, University of South Florida College of Medicine, James A. Haley Veteran's Hospital, Tampa, Florida 33612, USA. tlupoli@hsc.usf.edu
OBJECTIVE: To review and discuss the role of temporomandibular dysfunction (TMD) as a cause of chronic headaches and facial pain. DATA SOURCES AND STUDY SELECTION: A literature review was performed using the PubMed database for English-language articles published between January 1, 1981, and August 31, 2006, using the following keywords: temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache. Additional information was obtained from a review of current medical texts. RESULTS:. CONCLUSIONS: TMD is a likely underdiagnosed cause of chronic headache and facial discomfort. As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy. TMD can be readily diagnosed by a careful history and physical examination. Patients typically respond well to conservative therapy, which includes behavioral modification and nonsteroidal anti-inflammatory drugs. The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities.

PMID: 17941277 [PubMed - indexed for MEDLINE]

Labels: CGRP neuromuscular dentistry, facial pain TMJ, sinus headache, sinus infection, sinus pressure, TMD, TMJ sinus

A mechanism for retro-orbital pain and TMD is presented in this anatomical dissection of the the temporal branch of the zygomatic nerve passing through an accessory canal in the sphenozygomatic suture. This anatomical placement of the nerve would allow temporal muscle tension to cause nerve irritation and retro-orbital pain. Utilization of a diagnostic neuromuscular orthotic could differentiate retro-orbital pain that is best treated by neuromuscular dentistry.

Surg Radiol Anat. 2002 May;24(2):113-6.
Nervous branch passing through an accessory canal in the sphenozygomatic suture: the temporal branch of the zygomatic nerve.
Akita K, Shimokawa T, Tsunoda A, Sato T.

Unit of Functional Anatomy, Graduate School, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, Japan. akita.fana@tmd.ac.jp
A nervous branch which passes through a small canal in the sphenozygomatic suture is sometimes observed during dissection. To examine the origin, course and distribution of this nervous branch, 42 head halves of 21 Japanese cadavers (11 males, 10 females) and 142 head halves of 71 human dry skulls were used. The branch was observed in seven sides (16.7%); it originated from the communication between the lacrimal nerve and the zygomaticotemporal branch of the zygomatic nerve or from the trunk of the zygomatic nerve. In two head halves (4.8%), the branch pierced the anterior part of the temporalis muscle during its course to the skin of the anterior part of the temple. The small canal in the suture was observed in 31 head halves (21.8%) of the dry skulls. Although this nervous branch is inconstantly observed, it should be called the temporal branch of the zygomatic nerve according to the constant positional relationship to the sphenoid and zygomatic bones. According to its origin, course and distribution, this nervous branch may be considered to be influential in zygomatic and retro-orbital pain due to entrapment and tension from the temporalis muscle and/or the narrow bony canal. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0027-4.

PMID: 12197019 [PubMed - indexed for MEDLINE]

Labels: anatomical cause, CGRP neuromuscular dentistry, diagnostic orthotic, retro-orbital headache, retro-orbital pain

All patients with TMJ disorders especially if they get morning headaches or are tired during the day should be evaluated for sleep apnea. Sleep apnea (see www.ihatecpap.com) is a collapse of the airway during sleep.

Patients with clicking or popping TM joints will frequently have resolution of the TM Joint (temporomandibular joint) clicking if they wear a sleep apnea oral appliance.

The appliance stabilizes the condyle of the TMJ forward and if the disc is reduced allows time for the soft tissues to heal and stabilze the disc.

This stabilization will require the use of a daytime neuromuscular (splint) orthotic to maintain joint stability during the day.

Labels: CGRP neuromuscular dentistry, chronic daily headaches, facial pain TMJ, improving quality TMD, morning headache, temporomandibular joint, TMJ clicking, TMJ pain, TMJ popping

Much of this material is taken from my delanydentalcare.com website and from Sleep and Health's article on Neuromuscular Dentistry http://www.sleepandhealth.com/neuromuscular-dentistry which I highly suggest you read for a more detailed explanation of neuromuscular dentistry science and physiological principles.

Neuromuscular Dentistry is founded on the basic premise that healthy physiologic muscle function is basic to all of dentistry and medicine. The health of the underlying neurological systems, particularly those of the Trigeminal Nerve including the sympathetic and parasympathetic divisions. A corollary to this concept of healthy nerves and muscles is: Doctors do not heal their patients but rather they remove the impediments to healing and the body heals itself.

The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system’s control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque (and pathological muscle adaptation) during closure. This means that there are no noxious contacts to the teeth that are received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow “free” entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.

I founded Ihateheadaches.org, as a resource dedicated to educating and assisting those in need of headache, migraine and TMD diagnosis and treatment.

Neuromuscular dentistry is one of the most exciting fields of dentistry. The history of dental treatment has always been mechanical and primarily involved in repairing diseased and damaged tissues. This changed in 1934 when Dr. Costen, an otolaryngologist, in St Louis, Missouri described a series of problems in denture patients that eventually grew to become know as TMD or TMJ disorders. True to the mechanical background of dentists, they treated these problems as mechanical problems.

Centric Relation was a major concept in the background of treatment of TMD (TMJ) disorders (temporomandibular disorders). Centric Relation was a terminal hinge point of the TM Joints as determined by manipulation of the lower jaw by the dentist. There is stgill a large group of doctors who cling to this concept. There have been over 26 different definitions of centric relation over the years.

Wikipedia defines centric relation as "In dentistry, centric relation is the mandibular jaw position in which the head of the condyle is situated as far superior and anterior as it possibly can within the mandibular fossa. This position is used when restoring edentulous patients with removable or either implant-supported hybrid or fixed prostheses. Because the dentist wants to be able to reproducibly relate the patient's maxilla and mandible, but the patient does not have teeth with which to establish his or her own vertical dimension of occlusion, another method has been devised to achieve this goal. The condyle can only be in the same place as it was the last time it was positioned by the dentist if it is consistently moved to the most superior and anterior position within the fossa."

The problem with the entire concept of centric relation is that it makes the musclesand nerves secondary players in occlusion. The treating doctors muscles become more important than the patients normal nerve and muscle physiology and function. This all changed due a giant in dentistry Dr Barney Jankelson considered the father of Neuromuscular Dentistry.

Dr. Barney Jankelson, a board certified prosthodontist (specialty dentist), changed dentistry by making the muscles and neuromusculqr function of patients the center of treatment. He realized that while mechanics were important in treatment of headaches, TMj disorders and other painful conditions, the underlying muscle physiology was most important. Dr. Jankelson (or Dr J) as his friends called him developed methods of relaxing muscles and measuring physiologic parameters . His work was done in Seattle, Washington now known world-wide as the birthplace of Neuromuscular dentistry. The method to create healthy musculature depended on a dental occlusion

Due to the Knowledge of Dr. J. and many other great innovators, neuromuscular dentistry became the preeminent treatment for TMJ problems.

There was a major split in dentistry with many dentists clinging to their outdated mechanical views. These dentists still believe that the jaw joint or the temporomandibular joint is the most important aspect of treatment . They consider themselves to be Centric Relation dentists. Centric relation is the description of a joint position. The fallacy of this belief is reflected in the fact that the definition of centric relation continuously changes, and there are over 20 different definitions. The main belief of this group is that the muscles of the treating dentist's hands know better where the patients jaw should function than the patient's own relaxed healthy muscles. There is a third group of dentists who do not believe in the physical nature of these disorders and believe that pschotherapy, medication and biofeedback are the best way to treat all headaches and TMJ problems. They do not believe that the teeth and occlusion are involved in the development of TMD problems or are useful in treating these problems. They believe it is primarily a psychological problem though they frequently do not communicate this fact to their patients.

Neuromuscular Dentistry recognizes that the muscles, bones, joints and nerves of the masticatory system are the same in the masticatory region as in other areas of the body and that creating a healthy system by eliminating pathological function is basic to health.

There are other greats in Neuromuscular Dentistry.

Dr. Jim Garry was a pedodontist who described how airway and facial development affected the normal formation of the jaws and face. He was a great advocate of breastfeeding, and his work has changed the lives of tens of thousands of children.

Dr. Norman Thomas is an anatomist, physiologist and dentist who understood the science behind neuromuscular dentistry and how it related to total body health and posture. He is the brilliant man that still enables clinicians to integrate their clinical skills with the underlying basic science. He continues to do some of the most important work in all of dentistry at the Las Vegas Institute (LVI).

Robert Jankelson, Barney's son, carried on his father's work and wrote the first textbook on neuromuscular dentistry.

Janet Travell, who is one of the all time medical greats in the field of pain management and is known for her textbook Myofascial Pain and Dysfunction: A Trigger Point Manual. She was President Kennedy's personal physician. He had severe chronic pain and walked with a limp and cane due to war injuries. Dr. Travell changed his life by letting him live without severe pain.

Jackie Kennedy built the Rose Garden at the White House in her honor because Dr. Travell loved Roses.

I am Dr. Ira Shapira and I was fortunate to be students of these greats of neuromuscular dentistry. I have been practicing the art and science of neuromuscular dentistry for over 30 years . My partner Dr. Mark Amidei, has been with me for over 20 years and also practices using neuromuscular dentistry.

The Las Vegas Institute, considered the premier learning institute, was founded by Dr. Bill Dickerson. His background was from the Centric Relation mechanical school of thought but 10 years ago he had the great courage to abandon the outdated ideas and teach cosmetic reconstruction using neuromuscular ideals. Thousands of dentists around the world are now embracing the science of neuromuscular dentistry. Bill is one of the great men in cosmetic dentistry but he will be best remembered for his work in making neuromuscular dentistry available to the world. Dr Norman Thomas is now leading LVI in teaching and researching Neuromusclar dentistry. He is a great inspiration to his students who will represent the future of neuromuscular dentistry and research in this important field.

Traditional dentistry operates under the assumption that your jaw's acquired position is its optimum position. Neuromuscular dentistry, on the other hand is focused on finding the ideal position or range of positions for ideal health. This optimum position for your jaw is the basis for future work. This ideal position continually resets the neuromuscular system to a healthy physiologic condition.

My goal in utilizing Neuromuscular Dentistry is not just to treat a single tooth to solve a complex problem. Instead, we examine the entire neuromuscular and anatomical system of the head and neck in order to treat the whole patient, alleviating pain throughout the mouth and body.

We strive to treat the whole problem and give our patients a higher quality of life by aligning your jaw in the most comfortable position possible. Posture throughout the body is affected by the jaw and jaw function. The lower jaw acts like a counter balance for the skull as it sits atop of the spine much like the weights that are used in a doctors scale. You set the 50 and the 10 pound weights and the when you get the 1 pound weight perfectly adjusted the scale rests perfectly centered. If you move that weight even slightly in either direction the scale does not go slightly out of balance but rather it goes clunk. That is the effect disruptions in jaw function has on the entire body's postural balance. I tell my patients, You've been clunked.

Neuromuscular Dentistry;
Diagnostic and treatment modalities: There are two manufactures who make diagnostic equipment used by Neuromuscular Dentists, Myotronics and BioResearch. Myotronics was founded by Dr Barney Jankelson.

Warning!! All doctors that use these modalities do not practice neuromuscular dentistry. Some use the information as a baseline only!

MKG- Computerized Mandibular Scan
The mkg was invented by Dr. Barney Jankelson, DR. J, and it is designed to measure mandibular movement in 3 dimensions and track the jaw to understand both function and dysfunction. The name actually means study of mandibular movement. The name was changed to differentiate between neuromuscular dentistry and kinesiology, the study of movement elsewhere in the body. The scanner works by tracking a small magnet to the lower front teeth and tracking the magnets movement by sensors that do not touch the lower jaw. This allows the study of mandibular motion free of any interfering forces. Dr Shapira has been using an MKG for 28 years starting with an early model that utilized an ossciliscope to today's modern computerized scans. I The understanding based on ossciliscope findings have been verified by today's computers. Clinicians who learned on the ossciliscope usually have a deeper understanding than doctors learning on computers today. Today's computers do give a wealth of information that was not available in the past.

EMG or electromyography is utilized in conjunction with the MKG or CMS to evaluate the physiologic state and function of the masticatory (jaw) muscles and neck postural muscles. The EMG can be used to evaluate bilateral symmetry of the muscles, the health during rest and function, and can be used for incredibly accurate adjustments to the bite.

Emg is also used to measure the effectiveness of TENS in relaxing muscles. Neuromuscular dentistry typically uses bipolar adhesive skin electrodes that measure activity only. There is no discomfort involved during EMG testing. Effectiveness of muscle relaxation can be determined by EMG following use of TENS.

Dr Shapira and Dr Amidei have recently upgraed their myotronic equipment from the K6 to two new K7diagnostic systems.

TENS or transcutaneous electrical neural stimulation is at the heart of all neuromuscular dentistry. It is used to create a healthy relaxed state in unhealthy, diseased or spastic muscles. The Myomonitor is a specific type of TENS unit invented by Dr. Barney Jankelson that is used to relax masticatory and cervical musculature. The unit uses a very small electrical impulse to gently stimulate the muscles through a single synapse reflex (similar to the knee jerk done by physicians) repeatedly over an extended time. This action naturally relaxes the muscles. While some people don't think the process sounds natural I describe it as such because the repeated pulsing and relaxation pumps metabolic wastes out of the muscle cells and brings in blood with oxygen and nutrition, and the muscle relaxes as it heals versus the unnatural relaxation occurring by dumping chemicals or drugs into the system.

The pulses occur every 1.5 seconds and last only a 500th of a second. This time is set because it is the length of time it takes the cellular membrane to return to normal after stimulation. It is for this reason the muscles can be pulsed for an extended time without fatigue.

Borer associates have a similar TENS unit that is used for the same purposes but is slightly different in design. The slight differences usually do not matter, but for difficult long-term patients, each unit has its own peculiar advantages usually only appreciated by the very skilled and adept neuromuscular practitioner.

Both types of TENS are used in conjunction with the MKG and EMG to evaluate changes in mandibular position and function as the muscles are made healthier. Most problems are associated with long term accommodation pf muscle to less than ideal conditions. This results in a repetitive strain injury as the muscles must overcompensate for long periods of time.

The best way is to look at the diagnostic information gathered with these devices as aids that help the doctor make a more accurate diagnosis and plan effective treatment. If you go to the mall and look for a store, you will look up the store on the map and then look for the you are here arrow to figure out where you are in relation to where you are going. This information is vital to prevent treatment going in the wrong direction.

Transcranial neural transmitter modulation is a very unique type of TENS unit that is designed to stimulate the brain and create neurotransmitter changes in the brain similar to potent antidepressants without the chemical side effects.

Dr. Ira Shapira has been using this instrument as part of a diagnostic protocol to help understand and differentiate between peripheral disorders and problems arising from the CNS or central nervous system.

TENSing (Transcutaneous Electrical Neuromuscular Stimulation) muscles works out the lactic acid in your jaw muscles while working in fresh blood, oxygen, and nourishment for your jaw muscles. This helps relax your muscles and helps neuromuscular dentist Dr. Shapira to re-align your jaw to its relaxed neuromuscular rest position and establish an occlusion that lets the patients muscles return to a healthy state after use. The corrective alignment is usually done by a diagnostic orthotic. This allows initial treatment that is reversible until accurate diagnosis and successful phase 1 treatment is accomplished.

Phase 1 treatment is designed to find a functional position that stabilizes the jaw and allows healthy function in which the muscles naturally return to their relaxed state. Phase 2 treatment is long term stabilization with a more permanent orthotic cosmetic reconstruction orthodontic or surgical intervention. Avoidance of surgery is a top concern of Dr. shapira because there are so many complications related to surgery.

Neuromuscular dentist, Dr. Shapira, has been working with chronic head and neck pain patients for 30 years. His practice is dedicated to non-surgical alternatives to Temporomandibular Joint Dysfunction and drug-free pain management. He is certified to treat sleep apnea with FDA approved appliances as non-surgical alternatives to UP3 and Tracheotomy. He is a Diplomate of The American Board of Dental Sleep Medicine and TYhe American Academy of Pain Management. He understands the relation of jaw position and sleep apnea to all of the physical and biochemical disorder patients deal with. He has successfully treated hundreds of patients with a multitude of TM Joint problems, TMD and the myriad of related conditions. As a former sufferer of chronic pain, Dr Shapira made it a personal crusade to not only relieve his pain but to give patients a quality of life they never thought was possible.

Dr Shapira trained with Dr Janet Travell, the world's expert on myofascial pain and dysfunction and uses the techniques he learned from her to alleviate pain and restore normal function to his patients. Many experts consider fibromyalgia and myofascial dysfunction to be different subsets of the same disorder.

The I HATE Headaches website has a find a Dentist area that will continue to grow. If there is not a dentist in your area on the site currently contact Dr Shapira and he will help you locate a Neuromuscular Dentist in your area.

Labels: BioResearch, CGRP neuromuscular dentistry, find a neuromuscular dentist, Jankelson, K7, myotronics, pain management

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

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

I just attended the 2010 American EquilibrationSociety meetng in Chicago titled "TREATING THE TMD PATIENT: Putting the Puzzle pieces together". Great news for patients with migraines, tension headaches and Temporomandibular disorders.

The meeting opened with an excellent letter by Henry Gremillion, who was recently named Dean of the Louisiana School of Dentistry. He spoke on "MYOGENOUS OROFACIAL PAIN" or pain coming from the muscles. It is well known that the majority of pain has orgins in the muscles, including tension-type headaches and chronic daily headaches as well as most pain associated with TMD disorders.

Dr Gremillion quoted a scary study where a single injection of nerver growth factor, a compound found in sore muscles and around trigger points could activate nociception (pain) for up to 7 weeks not just in the area of injection but in distant muscular and joint areas. Because nerve growth factor is also released in painful areas it explains why treatment can take weeks to show effectiveness. These biochemical changes are associated with neuralplasticity and central sensitization.

There is also a cmlative effect where up to 50 first order neurons can feed into a single second order neuron leading to referred pain and explaining some of the complexity of dealing with headaches coming from muscles but mediated thru the trigeminal nerve and trigeminovascular system resulting in biochemical changes in the brain. While many physicians and some dentists seek to treat this pain with enormous amounts of medications it is possible to change the neural input and and positively effect the CNS (central nervous system) Chemical inbalnces in the brain can be triggered by peripheral nervous system input. A point that was emphasized by the second speaker Dr Jay Shah of the NIHwhose lecture "NEW FRONTIERS IN THE PATHOSPHYSIOLGY OF MUSCULOSKELETAL PAIN : ENTER THE MATRIX" was truly extraordinary in explaining the biochemical changes that occurs in and around trigger points.

Even more exciting is the use of ultrasound imaging and especially vibrational sonoelastography to measure the stiffness around myofascial trigger points and to show the effects on blood flow in the immediate vicinity of trigger points. He also showed that the same biological and chemical changes occur around both latent and active trigger points. These peripheral changes create central nrvous sytem biochemical changes via afferent nerves. He discussed how pain can be due to noxious stimulus or loss of "DESCENDING INHIBITION OF PAIN" AND HOW INHIBITORY NERVE APOPTOSIS CAN CREATE PERMANENT PAIN STATES. TIME IS OF THE ESSENCE IN ADDRESSING NEUROMUSCULAR PAIN! Dr Shaw is a senior staff physiatrist in the rehabilitation medicine dept. After hearing him speak about the treatment of pain and basic research into underlying causes I believe at least some of our tax dollars are truly being used wisely.

His croup does micrassay of the chemicals around myofascial trigger points and they are now using miniscule accupunture needles which have two chanels prepared with lasers to collect chemical assays painlessly with minimal disruption to the tissues. The work he describes should make all patients with myofascial pain and /or fibromyalgia hopeful for better lives with pain controlled. These studies put the rest the idea that TMJ disorders are psychosocial or physical. There is no longer any doubt about the medical nature of these muscle disorders.

Patients with chronic headaches and migraines will surely benefit as this type of research flourishes. This research is also proving the validity of many basic precepts of neuromuscular dentistry. Correction of periheral problems that sey off muscle nociceptors and endogenous biochemicals cause amplification and perpetuation of peripheral and central sensitization that lead to persistent pain.

DR GREMILLION ALSO DISCUSSED VARIOUS ETIOLOGICAL HYPOTHESIS OF CHRONIC MUSCLE PAIN THAT ALL CORRELATED WITH NEUROMUSCULAR DENTISTRY TREATMENT. The central hypothesis dealth with first order to second order neuron ratios, the repetitve strain hypothesis is exactly what neuromuscular dentistry treats with microtrauma leading to macro problems. The peripheral sensitization hypothesis explains how microtrauma can cause central sensitization and the central biasing Mechanism hypothesis explains the equilibrium shifts as facilitation and inhibition ratios shift. He also discussed Sympathetic Dysregulation that can lead to Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndromes (CRPS)

Labels: CENTRAL SENSITIZATION, CGRP neuromuscular dentistry, chronic daily headaches, CRPS, facial pain, fibromyalgia, myofacial pain, neuromuscular dentistry tmd, RSD, TMD, TMJ

Patients with thyroid problems frequently also have headaches, TMJ disorders and sleep disorders. The treatment of pain disorders frequently is aided by normalization of thyroid hormone. Free T3 is the activ e form of thyroid hormone and appears to be the most important thyroid hormone when dealing with chronic pain problems.

In the midwest theree is low naturally occuring iodine in the water. Patients with low thyroid and high TSH can frequently be helped by nutritional supplements containing iodine. 1 of drop of iodine in 8 oz of water every other day may be enough iodine to allow the thyroid to function normally. Many years age the Panda bears in Washington DC were unable to conceive. My uncle Dr Al Lepkovsky determined it was because of low thyroid. He added iodine to the water their bamboo shoots were grown in and their thyroid normalized and the pandas conceived and gave birth. Unfortunately they rolled on to of baby pandas and suffocated them.

Low thyroid is frequently treated with synthroid. Synthroid is the inactive (T4) form of thyroid hormone and many people are unable to convert it to T# the active form of the hormone. High TSH will be reduced by taking synthroid even if the active T3 is not increased at all. It has recently become more difficult to get natural Armour thyroid and many patients are getting it from Canada or compounding pharmacies. This is due to a questionable ruling by the FDA questioning the safety of Armour Thyroid natural thyroid hormone in spite of a 100 year safety history.

Sleep disruption can also cause aberrations in thyroid hormone levels. Sleep apnea is one type of sleep disruption. See http://www.ihatecpap.com for more information on the dangers of sleep apnea and treatment alternatives.

The frequent headaches, migraines and chronic daily headaches can be helped by a neuromuscular dental orthotic and/or by stabilizing thyroid hormone, particularly Free T3.

Patients with chronic headaches and migraines should have a thyroid evaluation done as well as sleep testing and neuromuscular dental evaluation.

Labels: CGRP neuromuscular dentistry, chronic daily headaches, Free T 3, Migraines, neuromuscular dentistry find a dentist, Synthroid, thryroid hormone

A new article in Medical Hypothesis (see Pub Med abstract below) on Atypical Trigeminal Neuralgia discusses the pathogenisis of Central Sensitization in patients with Trigeminal Neuralgia. A percentage of patients with Trigeminal Neuralgia will have pressure on the trigeminal nerve either from blood vessels or tumors usually in the area of the foramen ovale.

Many patients who have trigeminal neuralgia have no overt cause for the disorder. When there is a tumor or blood vessel creating undue pressure on the nerve a surgiclal approach is usually corrective but the central sensitization may remain. This article postulates that time is of the essence and the longer the pain persists the more likely that brain plasticity will lead to long term central sensitization. Decompression should be done ASAP according to that line of thought.

The majority of patients diagnosed with trigeminal neuralgia do not have tumor or blood vessels encroaching on the trigeminal nerve. It is well known that treatment of TMJ disorders is highly effective in reducing pain and that Neuromuscular Dentistry has been shown to be "overwhelmingly successful" according to Dr Barry Cooper and published in Cranio Journal.

The same rationale that says the key to preventing central sensitiztion is to address the problem as soon as possible also holds true with neuromuscular problems affecting the jaws, bite, jaw muscles and TMJ (TM Joints).

The effects of pressure on the trigeminal nerve are periferrral effects (noxius input) afecting the CNS. Neuromuscular bite problems are also noxious input from the periferal nervous system.

A second article in Medical Hypothesis "Migraine, neuropathic pain and nociceptive pain: towards a unifying concept." brought this to light and pushed the unifying concept of mifgraine and neuropathic pain. The basic concepts are identical. Correction of noxious input is the key to treating the pain and preventing central sensitization. This is exactly the concepts behind Neuromuscular Dentistry.

This is also explained in an excellent article on Myofascial pain and TMD published in J Pain. 2009 Nov;10(11):1170-8 (see PubMed Abstract below)"Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing." that is interesting because it looks at a group of 20-28 year old patients with myofascial pain, TMD and central sensitization. This group of patients definitively show how periferral pain manifestations induce central sensitization. The time to intervene with neuromuscular dentistry is at an earlier stage before central sensitization occurs.

There is also a concern about the quality of sleep as TMD patients have a much higher incidence of sleep apnea which I believe predisposes patients to central nervous system changes. Migraines, Chronic Daily Headaches, Tension-Type headaches and TMD are all directly effected by the trigeminal nerve and the trigeminovascular connection. Neuromuscular Dentistry can effect the central nervous system by changing the quality of neuro input.

Med Hypotheses. 2010 Feb 19. [Epub ahead of print]

Atypical trigeminal neuralgia: A consequence of central sensitization?
Hu WH, Zhang K, Zhang JG.

Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.

Trigeminal neuralgia (TN) is characterized by sudden, recurrent, usually unilateral, severe brief stabbing pains in the distribution of trigeminal nerve. Although it is widely accepted that blood vessel or tumor compression contributes to paroxysms of TN, the pathogenesis of persistent background pain in atypical TN patient is unclear. Central sensitization is pain hypersensitivity caused by central neural plasticity. It is responsible for many temporal and symptomatic features of acute and chronic pain. We hypothesize that central sensitization might account for some symptoms of atypical TN. Based on this hypothesis, we postulate that early medical intervention predicts good outcomes in TN and medicines which are effective on central sensitization may be potential agents for the treatment of atypical TN. Copyright © 2010 Elsevier Ltd. All rights reserved.

PMID: 20172658 [PubMed - as supplied by publisher]

Med Hypotheses. 2010 Feb;74(2):225-31. Epub 2009 Sep 17.

Migraine, neuropathic pain and nociceptive pain: towards a unifying concept.
Chakravarty A, Sen A.

Department of Neurology, Vivekananda Institute of Medical Sciences, Calcutta, India. saschakra@yahoo.com

Migraine, neuropathic pain and nociceptive pain are the three commonest pain syndromes affecting human. In the present article, we first present the salient features of the pathophysiology of the three conditions particularly highlighting the core features that are similar in the three conditions. We argue on the validity of the prevailing concept that maintenance of structural integrity of the nervous system differentiates nociceptive pain from neuropathic pain and point out that the fundamental pathophysiology of lasting nociceptive pain (like cancer pain) and neuropathic pain (like nerve injury pain) is essentially same. Migraine pathophysiology is complex and complicated by two opposing views on site of migraine pain generation - peripheral versus central. We hypothesize that this dichotomy has resulted from focusing on two different sites on a single, somewhat complicated, pain mediating circuitry from the peripheral meningeal and vascular structures through several cell stations in the brain stem and thalamus up to the sensory cortical matrix. At the end, we suggest that fundamentally all the three pain syndromes referred to in the article share a common pathophysiological mechanism, namely peripheral pain perception, peripheral sensitization at dorsal root ganglion or its intracranial counterpart (like trigeminal ganglion) and central sensitization at the spinal cord (dorsal horn for somatic pain), brain stem nuclei and thalamus before final pain perception at the sensory cortical matrix.

PMID: 19765908 [PubMed - in process]
that cause central sensitization and pain.

J Pain. 2009 Nov;10(11):1170-8. Epub 2009 Jul 9.
Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing.

.
Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P.

Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. cesar.fernandez@urjc.es

Our aim was to investigate bilateral, widespread pressure-pain hypersensitivity in nerve, muscle, and joint tissues in women with myofascial temporomandibular disorders (TMD) without concomitant comorbid conditions. Twenty women with myofascial TMD (aged 20 to 28 years old), and 20 healthy matched women (aged 20 to 29 years), were recruited. Pressure-pain thresholds (PPT) were bilaterally assessed over supra-orbital (V1), infra-orbital (V2), mental (V3) nerves, median (C5), radial (C6) and ulnar (C7) nerve trunks, the C5-C6 zygapophyseal joint, the lateral pole of the temporo mandibular joint (TMJ), and the tibialis anterior muscle in a blinded design. The results showed that PPTs were significantly decreased bilaterally over the supra-orbital, infra-orbital, and mental nerves, median, ulnar, and radial nerve trunks, the lateral pole of the TMJ, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with myofascial TMD as compared to healthy controls (all sites: P < .001). There were no significant differences in the magnitude of PPT decreases between the trigeminal and extratrigeminal test sites. PPT over the mental nerve, the TMJ, C5-C6 zygapophyseal joint and tibialis anterior muscle were negatively correlated to both duration of pain symptoms and TMD pain intensity (P < .05). Our findings revealed bilateral, widespread pressure hypersensitivity in women presenting with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD women. PERSPECTIVE: This article reveals the presence of bilateral and widespread pressure-pain hypersensitivity in women with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD. This finding has implications for development of management strategies.

PMID: 19592309 [PubMed - indexed for MEDLINE]

Labels: CENTRAL SENSITIZATION, CGRP neuromuscular dentistry, Facial pain trigeminal neuralgia, TMD Migraine, TMJ Migraine, trigeminal neuralgia neuromuscular dentistry

A recent article points to the use of CRCP (Calcitonin gene-related peptide) antagonists to treat migraines. Levels of CGRP rise during migraine and experimentally injecting IV CRCP can provoke migraine. Two CGRP antagonists are being tested inthe study from Acta Neurol Belg. 2009 Dec;109(4):252-61.

CGRP is produced by the trigeminovascular system. Many patients who undergo treatment with a diagnostic neuromuscular orthotic frequently see migraines decreased and/or eliminated. A future area of study would be does Neuromuscular Dentistry work by decreasing CGRP release from the trigeminal nerve. I consider most problems to be input/output errors of the trigeminal nervous system. Do noxious inputs from the teeth, jaw muscles, jaw joints, and periodontal ligament cause surges in CRGP in susceptible individuals causing migraine.


PubMed abstract
Acta Neurol Belg. 2009 Dec;109(4):252-61.
CGRP antagonists: hope for a new era in acute migraine treatment.
Schelstraete C, Paemeleire K.

Department of Neurology, Ghent University Hospital, Ghent, Belgium.
Calcitonin gene-related peptide (CGRP) has a widespread distribution throughout the trigeminovascular system and other brain areas involved in migraine pathogenesis. Serum levels of CGRP are elevated during the migraine attack and return to normal with alleviation of pain. Intravenous injection of CGRP in migraineurs results in delayed headache similar to migraine. Since CGRP receptor antagonists lack direct vasoconstrictor activity, this therapeutic approach may offer advantages over the current mainstay of specific acute migraine treatment with 5-HT1B/1D receptor agonists (triptans), contra-indicated in patients with underlying cardiovascular disease. Intravenous BIBN4096BS (olcegepant) and oral MK-0974 (telcagepant), two CGRP-receptor antagonists, were safe and effective in the treatment of migraine attacks in Phase I and II trials. In a Phase III clinical trial, the efficacy of telcagepant 300 mg was comparable to that of zolmitriptan 5 mg. We intend to review the rationale for the use of CGRP-receptor antagonists, and to outline current developments and future perspectives.

Labels: Calcitonin gene related protein, CGRP antagonist, CGRP migraine, CGRP neuromuscular dentistry, facial pain TMJ, neuromuscular dentistry migraine