Dr. Shapira's Chicago Headache Blog

A new study Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study in Headache. 2010 Feb 12 is very revealing. It was evaluating chronic daily headaches, pschiatric disorders and TMD. In the study "Individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH (chronic daily headache) were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2).

Of the 1631 subjects 57 (3.6%) had CDH. Chronic migraine comprised represented 36.8% and Chronic tension-type headache represented 17.5%. Medication overuse headache was also common representing 22.8% and probable medication overuse headache representing another 17.5% were also common combined totaling 40.3% of Chronic daily headaches

There were TMD comorbidities observed in 58.1% of the patients. This is no surprise as the trigeminal nerve is almost universally involved in chronic headaches. If a thorough neuromuscular detistry evaluation was done it is likely the percentage of patients with TMD signs or symptoms would be much higher. There were also psychiatric disorders were observed in a large percentage of these patients but living with chronic pain can frequently manifest itself in secondary psychiatric problems.

I frequently find that patients who are in chronic pain, not sleeping well and overutilizing medications change ramatically after they begin using a diagnostic orthotic. I sometimes feel I don't meet the patients until their second or third visit after significant pain reduction.

It is normal to be depressed when you are in constant non-remiting pain. I have frequently said that patients in constant pain who do not become depressed are "certifiable".

When considering comorbidities it is important to understand that TMD is a causitive comorbidity that helps create the chronic headaches while the psychiatric comorbidity may be a result of the pain or not related to the pain problem.

If one was to consider medication overuse a comorbidity then the data would skew considerably. Is the medication overuse headache a symptom of the underlying TMD or psychiatric disorder. Patients with TMD are prone to seeing a wide variety of health practitioners before being diagnosed with tmd (TMJ) disorders. TMD is know as "The Great Imposter" for that reason. Please see the Sleep and Health article "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

TMD IS SUCH A MAJOR COMORBIDITY IN HEADACHES THAT EVERY PATIENT WITH CHRONIC HEADACHES OR MIGRAINES SHOULD BE EVALUATED FOR TMD PRIOR TO INITIATING MEDICATION. A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC MAY ELIMINATE THE PAIN PROBLEMS THEREBY AVOIDING FUTURE MEDICATION OVERUSE HEADACHES AND ASSOCIATED PSYCHIATRIC PROBLEMS FROM BOTH PAIN AND MEDICATION OVERUSE.





PUBMED ABSTRACT below
Headache. 2010 Feb 12. [Epub ahead of print]
Chronic Headache and Comorbibities: A Two-Phase, Population-Based, Cross-Sectional Study.
da Silva Jr A, Costa EC, Gomes JB, Leite FM, Gomez RS, Vasconcelos LP, Krymchantowski A, Moreira P, Teixeira AL.

From the UFMG - Headache Clinic, Belo Horizonte, Brazil (A. da Silva Jr, E.C. Costa, J.B. Gomes, and F.M. Leite); University Hospital, Federal University of Minas Gerais - Headache Clinic, Neurology Division, Belo Horizonte, Brazil (R.S. Gomez); Federal University of Minas Gerais (UFMG) - Internal Medicine, Belo Horizonte, Brazil (L.P. Vasconcelos and A.L. Teixeira); Universidade Federal Fluminense - Neurology, Rio de Janeiro, Brazil (A. Krymchantowski); Universidade Federal Fluminense - Headache Clinic, University Hospital, Rio de Janeiro, Brazil (P. Moreira); Federal University of Minas Gerais (UFMG) - Laboratory of Immunopharmacology, Belo Horizonte, Brazil (A.L. Teixeira).
Background.- Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking. Objectives.- To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil. Methods.- This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively. Results.- A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them. Conclusions.- The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers. (Headache 2010;**:**-**).

PMID: 20163479 [PubMed - as supplied by publisher

Labels: Chicago, chronic daily headacahe, chronic daily headaches, chronic daily migraine, comorbidities, facial pain TMJ, ILlinois, Kenosha, lake county, TMD

The following is a reprint of my article I was asked to write for the American Equilibation society. There are a couple of pictures that are not included in the text but can be found on the Sleep and Health Journal Site @ http://www.sleepandhealth.com/neuromuscular-dentistry

This article was written to explain Neuromuscular Dentistry to TMJ dentists who are not familiar with the field. I firmly believe that all TMJ treatment is better if neuromuscular dental techniques are used to perfect position.

I HAVE ALSO INCLUDED AFTER MY ARTICLE AN ABSTRACT OF AN ARTICLE BY BARRY COOPER DDS IN CRANIO WHERE HE FOUND "OVERWHELMING RELIEF" IN PATIENTS WITH NEUROMUSCULAR ORTHOTIC USE.

Dr Cooper has done an enormous service to all headache sufferers by his careful documentation of treatment. Insurance companies no longer have any justification for not covering neuromuscular dentistry in total. He is also a Past President of ICCMO and the founding Chairman of the Alliance of Temporomandibular disorders.

Neuromuscular Dentistry
NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)

Ira L Shapira DDS, DABDSM, DAAPM, FICCMO

Neuromuscular Dentistry remains an enigma to many dentists who do not understand the purposes of the electrodes, the TENS, the computers and more. It has unfairly become a target of poor and misleading definitions by doctors who do not understand its basic principles.

There are several basic premises that underlie Neuromuscular Dentistry. The first premise is that the stomatognathic muscles are the primary determinate of the mandibles position during all jaw functions (when the teeth are not in occlusion) and that rest position is one of the most important positions in dentistry. Rest position is a maxillary to mandibular jaw relation where the teeth are not in occlusion but are prepared to occlude. In Neuromuscular Dentistry Rest is a position of bilaterally equal and low muscle tonicity from which the mandible moves into full occlusion with minimal muscle accommodation. Following closure from rest position the mandible should return to rest with similarly balanced low muscle tonicity. Rest position is determined not only by the mandibles relation to the cranium but also by the position of the head relative to the body, the suprahyoid and infrahyoid muscles and the position of the hyoid bone. To fully understand the relation of jaw movement to head posture read the Quadrant Theorem of GUZAY (Available from the ADA Library). In essence it shows in engineering terms that after accounting for both rotation and translation of the mandible the actual axis of rotation of the mandible is at the odontoid process of the second vertebrae not at the mandible condylar head.

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 during closure. This means that there are no noxious contacts 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.

Swallowing is a primary activity when the jaw is closed into full occlusion. In order to swallow it is necessary to fixate the mandible and this happens as the teeth occlude. During chewing, speaking and other jaw functions the teeth do not actually occlude in normal function but are separated (during chewing by a bolus of food). Typically swallowing occurs approximately 2000 times a day and is momentary accounting for 6-10 minutes maximum time in occlusion over the course of the day and acts as a neuromuscular reset switch for trigeminally innervated muscles. During a healthy swallow the teeth will move freely without interference into full occlusion with bilateral equal contact and bilateral equal muscle activity and then return to rest position with low muscle tonicity. A deviate swallow as evidenced by scalloping of the tongue is a sign of a possible TMJ disorder and is also 80% predictive of sleep apnea (80% predictive in Dental study- 70% predictive ENT study)

Neuromuscular occlusion (myocentric) occurs when centric occlusion (maximum non-torqued intercuspation of teeth) is coincidental with a balanced muscle closure where the muscles will return to their relaxed state following closure. Myocentric is the ideal position for swallowing.

The dentist utilizing neuromuscular techniques does not determine a specific position of the condyles in the fossa. The position of the disk and condyle are determined primarily by the teeth (bite or orthotic during occlusal correction therapy) in occlusion (myocentric) and the application of muscle activity. Neuromuscular dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a neuromuscular reset switch during closure. Neuromuscular dentistry rejects the notion that manipulation of the patient's jaw by the intervention of the clinician muscles are more important in determining the relation of the components of the TM Joint than the muscles of the patient. Centric relation is not used as a reference position for mounting casts on an articulator. Centric Relation is considered a border movement of the mandible and as reported in orthopedic literature joints are rarely used in their border positions.

The HIP plane (defined by hamular notches, incisive papilla and the occipital condyles) and/or Campers plane is used to relate the maxilla to an articulator. When cosmetic considerations are involved photos are used to to incorporate this physiologic plane to soft tissues of the face. Ideally the occlusal plane (parallel to the HIP Plane) will bisect the odontoid process of the axis of the atlantoaxial joint the actual center of rotation for the mandible after accounting for translation and rotation according to the quadrant theorem.

This occlusal plane will be at a 90-degree angle to gravitational force when the head is in an upright position. A neuromuscular bite is used to mount the


mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409

Neuromuscular dentistry considers many of the problems associated with TMD to be repetitive strain injuries. Movements become harmful when closure requires excessive accommodation and then the system fails at its weakest link. If the weakest link is muscle health we will see formation of tender sore muscles with eventual formation of taut bands and trigger points. If there is muscle overuse from clenching and/or grinding there will be post exercise pain secondary to anaerobic lactic acid build-up. If the weakest point is in the TM Joint then when repetitive strain occurs the muscle accommodation will lead to increased intra-articular pressure. This again will break down the joint at its weakest point. This may occur as a displaced disk or as wear of articular surfaces or many other conditions. It may come at the expense of the bone of the condyle leading to flattening or beaking of the condyle. Clenching and bruxism are two particularly well-known and harmful parafunctional habits that lead to varied repetitive strain injuries. There are many other parafunctions that can lead to problems. Some parafunctions are actually protective muscle accommodation such as the deviated or reversed swallow that protects the TM Joints and masticatory muscles at the expense of altered head, hyoid and spine position and consequent muscle problems.

The second type of problems would be described as I/O or Input/ output errors in computer lingo. The CNS is essentially a biological computer and is affected by input from afferent nerves from the body. Autonomic system function include the fight or flight response with concomitant release of adrenaline that alters the heart rate, blood pressure, muscle tone etc. This system effects the Hypothalamus pituitary complex with feedback to the adrenals and effects on ACTH and cortisol levels. During periods of acute stress these effects have a positive survival value but during chronic stress become a liability to the individual as described by Hans Selye in his book “The Stress of Life” and his discussion of the General Adaptation Syndrome. There are numerous biochemical changes that occur in the brain secondary to aberrant or nociceptive input into the brain these can be affected by correction of the neurological input, by using drugs to change the brain chemistry or a combination of these approaches. Ideally correction of the underlying cause of these biochemical changes is the preferred method of treatment.

The utilization of TENS or transcutaneous neural stimulation over the coronoid notch has been shown by Mitani and Fujii (1974 J. Dent Res.) to block the motor division of the trigeminal nerve and relax the musculature via anti-dromic impulses (hyperpolarisation) to both the alpha and gamma motor neurons without influence from proprioceptive and nocioceptive (tooth contacts) inputs The TENS is then use to create a balanced synchronize pulsing to find the trajectory of closure where a myocentric registration can be obtained. The muscles will return to their relaxed position following closure into myocentric.

The use of Computerized mandibular jaw tracking allows the dentist to measure and record resting jaw position relative to the cranium at a given head position. The location of myocentric occlusion is determined by the dentist with the aid of information from tracings recorded.

Electromyography or EMG is used to record relative values of resting muscle activity of masticatory muscles as well as muscles such as Sternocleidomastoid or Trapezius. While there are no absolute “normal values” of resting muscles the clinician uses his information to compare muscle activity within a given patient. Muscles should be approximately equal activity bilaterally. Thomas 1990 in Frontiers of Oral Physiology vol 7 pp162-170 demonstrated that Spectral analysis of the post TENS EMG may be utilized to evaluate muscle fatigue and differentiate between muscle atrophy or fatigue or relaxed muscle states. This was later confirmed by Frucht, Jonas and Kappert at Frieberg University in 1995 (Fortschr.Kieferorthop vol 56 pp 245-253)

Utilizing the two modalities together allows the clinician to evaluate the rest position of the jaw and simultaneously the health and functional activity of the muscles.

The EMG also allows tests to evaluate the functional capacity of the muscles and again compare the right and left sides for symmetry. The use of functional recordings (during clenching and closure into centric occlusion) allows the clinician to evaluate whether or not muscle function is satisfactory and functional. The use of EMG also allows evaluation and correction of first contact of closure position within microseconds bases on firing order of the masseter and temporalis muscles. The first point of contact on closure is vitally important and equilibration of orthotics and dentition must be finely adjusted until first contact is evenly dispersed on posterior dentition.

Neuromuscular dentistry is very concerned with the effects of mandibular position on the body as a whole and on the effects of the body on jaw and head position. The work of Sherrington and the righting reflex explains how ascending and descending disorders affect a patient. These phenomena have been best explained by Norman Thomas BDS, PhD. I will not attempt to explain this complicated topic in this agenda, which may be found in Anthology of ICCMO vol V pp159-170. It obviously must incorporate the Quadrant Theorem of Casey Guzay, the physiological aspects of the balance organ of the inner ear and the vestibular apparatus located in the brainstem as well as visual feedback. The control of sympathetic and parasympathetic systems by the cerebellum is quite intricate and also affected by head position.

Correction of the chewing cycle is an important part of occlusal finalization. It must be understood that the chewing cycle is different on the each side and that interferences can occur on both the opening and closing strokes of the chewing cycle. Interferences in chewing strokes are easiest to detect by study of the chewing strokes on computerized mandibular scans (MKG). Head position during chewing is not is normally in the upright head position but in the feeding position approximately a 30-degree anterior head flexion. Correction of the chewing cycle is at least as important as correction of right, left and protrusive excursions. Chewing is a healthy function of the craniomandibular apparatus where as excursive movements are actually exercises in parafunctional movements.

There is more commonality to treatment of TMJ disorders by neuromuscular and non-neuromuscular dentists than differences and complications caused by neural intensification in the reticular activating system, emotional aspects and the relation to the limbic system, connections to the sympathetic and parasympathetic nervous systems via the Sphenopalatine Ganglion and sympathetic chain, and chemical changes and cerebroplastic changes that occur during chronic pain leading to hyperalgesia and allodynia all can be discussed in greater detail and explained in relation to neuromuscular dentistry. The basics physiology including effects of Golgi tendon organs and muscle spindles on jaw muscles remain constant and must always be carefully considered during treatment.

Barney Jankelson's famous quote, "If it is measured it is a fact otherwise it is an opinion rings as true today as when he first said it. Neuromuscular dentistry is about making accurate measurements and the use of those measurements to improve the doctor's ability to make a differential diagnosis and tailor treatment to relieve pain and create stable restorative dentistry with healthy relaxed musculature.

I would like to make a disclaimer that this is my personal definition of Neuromuscular dentistry from 30 years of practice and to thank my mentors Barney Jankelson, Barry Cooper, Dayton Krajiec, Richard Coy, Harold Gelb, Peter Neff, Robert Jankelson and especially Jim Garry who first made me understand the connections between increased upper airway resistance and the common developmental aspects of sleep apnea and craniomandibular disorders. A special thank you for Dr Norman Thomas for his extraordinary help in understanding the complex physiology and anatomy underlying neuromuscular dentistry and in reviewing this paper prior to presentation.

My personal research in the 1980's as a visiting assistant professor at Rush Medical School examined the jaw relations of patients with obstructive sleep apnea based on neuromuscular evaluations of jaw relations with a Myotronic's kinesiograph and a myomonitor to find neuromuscular rest position. These studies showed jaw relations in the male apnea patients that were strikingly similar to those found in female TMD patients. The National Heart Lung and Blood Institute considers sleep apnea to be a TMJ disorder. The NHLBI published a report, “Cardiovascular and Sleep Related Consequences of TMJ Disorders” in 2001 that can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

Dr Shapira returned to Rush as an assistant professor at the sleep center in the 1990's where he treated a wide variety of obstructive apnea patients with commercial and customized intraoral sleep appliances. He was a founding and credentialed member of the Sleep Disorder Dental Society that has become the American Academy of Dental Sleep Medicine, He is a Diplomate of the American Board of Dental Sleep Medicine, on the board of the Illinois Sleep Society, a Diplomat of the American Academy of Pain Management, a Regent Fellow of the International College of Cranio-Manibular Orthopedics and a representative of that group to the TMD Alliance. He is a long time member of AES, AACFP, Academy of Sleep Medicine and the Chicago Dental Society. Dr Shapira teaches hands-on in-depth Dental Sleep Medicine courses to small groups at his Gurnee office. A family history of genetic cancer led Dr Shapira into research on stem cells an he also holds several patents (method and device) on the collection of stem cells during early minimally invasive removal of the uncalcified tooth bud of developing third molars. This procedure can be complete in minutes with greatly reduced morbidity compared to current surgical techniques used for removal of developed third molars. He hopes in the future that patients will routinely remove the tooth buds and collect and save the stem cells for anti-aging and regenerative medical uses.


PUBMED ABSTRACT FOLLOWS:
Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. tmjbcooper@aol.com
Comment in:

Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

PMID: 18468270 [PubMed - indexed for MEDLINE]

Labels: barrington, Chicago, Gurnee, headache specialist, libertyville, migraine treatment, neuromuscular dentistry, spenopalatine block TMJ, tmd.tmj/tmd/temporomandibular disorders.tmj specialist

I have received several e-mails from patients who tell me that there are no dentists listed in their area. We will help you find a Neuromuscular Dentist in your area. I practice in Gurnee, Illinois and see patients primarily from Northern Illinois and Southern Wisconsin. I can do some procedures and initial consults on TMJ disorders at the offices of Chicagoland Dental Sleep Medicine Associates in Skokie and Schaumburg but patients with difficult headaches usually need to come to Gurnee. My office is especially convenient for North Shore suburbs of Chicago as well as Northwest suburbs.

I teach a course in Dental Sleep Medicine to dentists from around the U.S. and my team can arrange for out of own patients who want to travel to Chicago for Neuromuscular Dental Treatment.

Neuromuscular Dentistry for Treatment of headaches involves at least two extended appointments at the start of treatment. Ideally out of town patients will spend three days to begin treatment. The first visit for local patients is usually a consultation we can start treatment for long distance patience if previous arrangements are made.

Following the consultation appointment, treatment begins at the first appointment with a comprehensive examination and neuromuscular work up. The diagnostic orthotic is deliverd at the second visit visit. Long distance patients actually have a full day of treatment (the equivlant of two appointments) with the appliance being delivered on the first day. The patient will be seen early the next day for correcting the diagnostic orthotic to rflect changes in posture as muscles continual to release and normalize. A second visit in the afternoon will often include nerve blocks or trigger points if there is still residual pain. Some patients will leave after the second day but I prefer to have their next appointment the morning of the third day before they go home. We will usually schedule the next vist for 2 weeks later but if pain is completely relieved we may postpone the next appointment.

All patients are different and bring unique challenges and treatment is adjusted to individual patients. Many patients bring their spouse to the first series of appointments though this is not necessary.

Diagnostic orthotics are used in phase I treatment. The diagnostic orthotic is meant for a few months of use decrese pain and stbilize posture. If the patient decides they are substantially improved we recommend a second phase of treatment for long term stabilization. Long term stanilization and permanent changes are usually avoided at the initial series of visits.

Long term stabilization can take many different forms but it is designed to maintain the relief afforded by the diagnostic orthotic.

Labels: Chicago, diagnostic orthotic, Headache treatment, il, phase 1, TMD, TMJ, Wi

A new article in the Clinical Journal of Pains shows that patients who develop TMD have increases in Headaches & Migraines but also have significant increases in other bodily pains. In addition to increase in headaches patients who were diagnosed as developing TMD had increases in muscle and joint pain, back pain, chest pain, abdominal pain and menstrual pain.

The study was done on 266 female patients aged 18-34 years old who initially were free of TMD symptoms. Over 5% of the population developed new TMD symptoms. There is no question that the majority of headaches are caused by the trigeminal nerve (dental Nerve) what this study sees to imply is that the trigemino system may increase perception of pain throughout the body. This may be do to central sensitization. This is a rationale for utilizing neuromuscular dentistry to treat patients early to prevent a local problem from becoming widespread.

Dr Barry Cooper has shown an "overwhelming" positive effect on headaches and TMJ disorders with Neuromuscular Dentistry. A neuromuscular dentist has the training and equipment necessary to evaluate physiologic parameters and idealize occlusion to reduce or eliminate TMD symptoms and Headaches and prevent a local problem from becoming a whole body problem.


Clin J Pain. 2010 Feb;26(2):116-20.
Development of temporomandibular disorders is associated with greater bodily pain experience.
Lim PF, Smith S, Bhalang K, Slade GD, Maixner W.

Center for Neurosensory Disorders, School of Dentistry, University of North Carolina at Chapel Hill, NC 27599-7455, USA. peifeng_lim@dentistry.unc.edu
OBJECTIVES: The aim of this study is to examine the difference in the report of bodily pain experienced by patients who develop temporomandibular disorders (TMD) and by those who do not develop TMD over a 3-year observation period. METHODS: This is a 3-year prospective study of 266 females aged 18 to 34 years initially free of TMD pain. All patients completed the Symptom Report Questionnaire (SRQ) at baseline and yearly intervals, and at the time they developed TMD (if applicable). The SRQ is a self-report instrument evaluating the extent and location of pain experienced in the earlier 6 months. Statistical analysis was carried out using repeated measures ANOVA. RESULTS: Over the 3-year period, 16 patients developed TMD based on the Research Diagnostic Criteria for TMD. Participants who developed TMD reported more headaches (P=0.0089), muscle soreness or pain (P=0.005), joint soreness or pain (P=0.0012), back pain (P=0.0001), chest pain (P=0.0004), abdominal pain (P=0.0021), and menstrual pain (P=0.0036) than Participants who did not develop TMD at both the baseline and final visits. Participants who developed TMD also reported significantly more headache (P=0.0006), muscle soreness or pain (P=0.0059), and other pains (P=0.0188) when they were diagnosed with TMD compared with the baseline visit. DISCUSSION: The development of TMD was accompanied by increases in headaches, muscle soreness or pain, and other pains that were not observed in the Participants who did not develop TMD. Participants who developed TMD also report higher experience of joint, back, chest, and menstrual pain at baseline.

PMID: 20090437 [PubMed - in process]

Labels: Chicago, cluster headaches, Lake Forest, neuromuscular dentistry, TMD

A recent email brings up many interesting questions. My comments follow this distressing case.

"I am writing this on behalf of our 21 year old son who has dealt with frequent headaches since kindergarten. The headaches have gotten more frequent and more severe as the years have gone by. Currently, he averages 4-5 headaches a week and approximately 2 migraines a month.
He takes Extra Strength Excedrin at the first sign of a headache. If there is no relief within 30 minutes, he will take a Relpax. We have tried food diaries, monitoring sleep patterns, massage therapy, chiropractors, and even sought 3 surgeons asking if his non-union clavicle could possible be the source of his headaches. He has tried Topomax, but no longer takes it daily.
He has had orthodontic work done and now wears a retainer nightly. Only recently have we thought to consider sleep apnea (he has always been a very restless sleeper; i.e. tossing and turning) and possibly TMJ. He is seeing a dentist tomorrow (1/14) and will ask about the TMJ.
Is it possible that this could be the cause of his headaches? I know my son would be thrilled if he could just have one headache a month! Even if it were a migraine, it would be better than what he is dealing with currently.
Thank you for your time, and I apologize if this is the second email you have received from me. I am sending this from work and because I have not heard from you, I am not sure you received my previous post."

Reply
This case brings up many interesting questions. When do the headaches occur? Does the patient wake in the morning with headaches or does pain wake him from sleep. Patients that only occur in the morning can sometimes be treated with a nightime only appliance but sleep apnea must be ruled out as a causes. The most common causes of morning headaches are sleep apnea and TMD (includes bruxism and clenching) TMD does not always have pain or clicking in the joint.

A second question is how much extra strength Excedrin (and caffeine) A patient can have a medication rebound headache as well. Orthodontics can make headaches, sleep apnea and TMJ problems better or worse or have no effect. If the ortho pulled the jaw back it is likely to make the problem worse. Also, was there bicuspids removed to treat the case? Removal of teeth, in my experience usually will make sleep apnea worse.

As discussed in previous posts Sleep Apnea is a TMJ disorder and I strongly Rx anyone with morning headaches, migraines or TMJ disorders read the NHLBI (National Heart Lng and Blood Institue) article "CARDIOVASCULAR AND SLEEP-RELATED
CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

The following is excerpted from the NHLBI paper:

"Mandibular Movements, Upper Airway Resistance, Breathing and Swallowing
There appears to an associated increase in coughing in subjects with sleep apnea. Occlusion of
the pharynx can force residual secretions into the glottis and trigger coughing reflexes,
swallowing reflexes, and other reflexes that could contribute to the disorganization of breathing
during sleep. In addition to the muscles of mastication, the tongue plays an important role in
the coordinated events of swallowing and breathing. The integration of breathing and
swallowing is tightly linked, and these events in turn are in some manner linked to blood
pressure regulation. Each of these pathways has been studied by scientists in individual
disciplines, but there is a need for interdisciplinary studies to determine the interactions of the
peripheral and central neural pathways controlling breathing, chewing, swallowing, and
cardiovascular events. The presence of pain in patients with TMD would be expected to
seriously impact upon these reflex and motor pathways. Little is known about the role of tongue
position and how this may be altered in subjects with altered jaw location and structure. Sleep
state has been shown to alter the central modulation of the coordination of breathing, airway
dynamics, swallowing, and associated cardiovascular events. Differences in central modulation
of these events in subjects with sleep apnea and TMD need to be evaluated using sleep as a
dynamic change in the state of the individual."

The paper also suggests 60-90% resolution which frequently occurs in treatment. I believe that Neuromuscular Dental treatment increases that success rate considerably.

Neuromuscular Dentistry has been shown to be "overwhelmingly successful according to Dr Barry Cooper's research reported in Cranio. The PubMED abstracts are include at the bottom of the post for convenience.

Other questions include what were the effects of physical medicine such as Chiropractic and massage and were the treatment combined. Was there no relief or only temporary relief. When either of those therapies only gives temporary relief you should suspect a problem with the neuromuscular bite position. TMD is a repetitive strain condition and breathing and swallowing as well as postural conditions can effect the bite just as the jaw position effects the entire bodies balance. The strongest influence on headaches is thru the trigeminal nerve.

An excellent way to both diagnose a cause and effect of jaw muscles to headache pain is the use of trigger point injections and diagnostic blocks. Frequently a severe headache can be relieved by judicious use of TP injections. Recurrent headaches are usually less frequent and severe if successful.

Cranio. 2009 Apr;27(2):101-8.
Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology of the State University of New York (SUNY) Stony Brook School of Dental Medicine, NY, USA. tmjbcooper@aol.com
A prominent etiological theory proposed for TMD related headache is that it results from a dysfunctional masticatory muscle system, wherein muscle hyperactivity is frequently caused by dental temporomandibular disharmony. The central goal of this article was to determine from a literature review of the subject whether there is significant evidence to support a relationship between headaches and TMD prevalence. A second purpose was to determine from such a review whether any relationship was one of cause and effect and whether treatment of the TMD condition can result in meaningful reduction or resolution of headaches. In the literature, there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type. Evidence for a cause and effect relationship was strong. It generally showed in numerous patients that TMD treatment of a large number of patients resulted in significant improvement in the physiological state of the masticatory system (muscles, joints and dental occlusion). Reduction or resolution of muscle tension-type headaches that were present was clinically significant. The authors concluded that TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches in patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition.

Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. tmjbcooper@aol.com
Comment in:

Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

PMID: 18468270 [PubMed - indexed for MEDLINE]

Labels: Chicago, il, neuromuscular dentistry, ortho, TMD, Topomax

Chronic Daily Headache which affects 2-4% of female adolescents and as high as 2% of males can have a devastating effect on children. They usually occur with a chronic baseline headache with episodes of severe migraine-like are severe in intensity. This condition can last for months and there is no known underlying pathology. A neuromuscular dentist (NEUROMUSCULAR DENTISTRY http://www.sleepandhealth.com/neuromuscular-dentistry) should evaluate these patients early in treatment after organic disease is ruled out. Children are experiencing numerous changes at this period of their life including changes in hormonal status, increase peer pressures in school as well as increasing demands from school. They are also frequently going thru transitional dentition.

The advantage to orthotic treatment is there is at least a 50-80% improvement in the majority of patients treated with an orthotic. Even this partial relief could be life changing. If there is a primary problem related to jaw function and/or trigeminal nerve function Neuromuscular Dentistry allows early correction and orthodontics for case completion. It must be recognized that this condition frequently begins during orthodontic treatment.

Children with Chronic Daily Headache (CDH) problems have associated symptoms including sleep disturbances, other pain problems, dizziness that frequently results in school absence. Temporomandibular disorders are also known to cause severe Tension-Type headaches as well as other symptoms including facial pain, neck pain dizziness, ear pain, stuffy ears , sinus pain and sleep disorders. The National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ disorder in their report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" The report defines The term TMD as "a collection of MEDICAL and dental conditions affecting the temporomandibular joint (TMJ) and/or muscles of mastication, as well as contiguous tissue components. Symptoms range from occasional discomfort to debilitating pain and severely compromised jaw function. The masticatory apparatus is not only involved in chewing and swallowing but also in other critical tasks, including breathing and talking. This is not a dental problem but a medical problem that can cause wide spread problems including Migraines, Chronic Daily Headaches, Episodic Tension Type Headaches and Morning Headaches.

CDH is frequently associated with medication-overuse headache which is a bigger problem in children than adults as it can lead to a lifetime pattern of overuse. CDH is known to have "psychiatric comorbidity (anxiety and mood disorders) these may be a direct result of living with severe pain but may also be do to sleep apnea or other sleep disorders such as primary insomnia that is suspected as an etiology for central sensitization. The NHLBI report states " Pain linked to the TMJ and/or muscles of mastication constitutes the essential criterion for case assignment. It often qualifies as “aching”, “throbbing”, “tiring” and exhausting. About 60-90% of cases appear to experience satisfactory resolution of symptoms with a range of interventions. In contrast, the remaining group of patients does not respond well to these treatments and continues to exhibit persistent pain. Comorbid complaints, such as problems with sleep, blood pressure and breathing are not uncommon for this group of TMD patients but have not been well characterized. " The report of 60-90% relief is astounding compared to reports from neurological journals. Cases should be evaluated for TMD by a neuromuscular dentist for early treatment to lower the risk of developing central sensitization and a lifetime of chronic headaches and/or migraines. While there is a group reported to not respond to treatment it is a minority of patient.

This view is supported by Dr Barry Cooper in his paper " Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment." published in Cranio in April 2009. He reported "there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type". Dr Cooper reported " Evidence for a cause and effect relationship was strong." The paper concluded that "TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches in patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition." Early treatment to prevent progression is the ideal but relief of symptoms for 60-90 % of children as reported by the NHLBI would be sufficient to warrant evaluation of all pediaric and adolescent headaches.

Another paper in Cranio by Cooper BC, Kleinberg I. "Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients." reported Patients reported "overwhelming symptom relief" This study was based specifically on neuromuscular dental treatment and the results were overwhelming including "reduction of headaches and other pain symptoms." Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

Unfortunately both adult and pre-adult patients are often not referred for neuromuscular dental evaluation for numerous reasons. A surprising reason is that physicians are not comfortable referring to dentists. This is beginning to change as physicians see excellent results of treatment of sleep apnea with oral appliances (http://www.ihatecpap.com/oral_appliance.html) and the medical community recognizes the effects of periodontal disease on chronic inflamation, cytokines and the cardiovascular effects of these changes.






PubMed abstract below:
Rev Neurol (Paris). 2009 Jun-Jul;165(6-7):521-31. Epub 2008 Nov 28.
[Management of chronic daily headache in children and adolescents]
[Article in French]

Cuvellier JC.

Service de neuropédiatrie, clinique de pédiatrie, hôpital Roger-Salengro, centre hospitalier régional et universitaire de Lille, rue du Professeur-Laine, 59037 Lille cedex, France. jc-cuvellier@chru-lille.fr
Chronic daily headache (CDH) affects 2 to 4% of adolescent females and 0,8 to 2% of adolescent males. CDH is diagnosed when headaches occur more than 4 hours a day, for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, without an underlying pathology. It is manifested by severe intermittent headaches, that are migraine-like, as well as a chronic baseline headache. Silberstein and Lipton divided patients into four diagnostic categories: transformed migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. The second edition of the International Classification of Headache Disorders did not comprise any CDH category as such, but provided criteria for all four types of CDH: chronic migraine, chronic tension-type headache, new daily-persistent headache, and hemicrania continua. Evaluation of CDH needs to include a complete history and physical examination to identify any possibility of the headache representing secondary headaches. Children and adolescents with CDH frequently have sleep disturbance, pain at other sites, dizziness, medication-overuse headache and a psychiatric comorbidity (anxiety and mood disorders). CDH frequently results in school absence. CDH management plan is dictated by CDH subtype, the presence or absence of medication overuse, functional disability and presence of attacks of full-migraine superimposed. Reassuring, explaining, and educating the patient and family, starting prophylactic therapy and limiting aborting medications are the mainstay of treatment. It includes pharmacologic (acute and prophylactic therapy) and nonpharmacologic measures (biobehavioral management, biofeedback-assisted relaxation therapy, and psychologic or psychiatric intervention). Part of the teaching process must incorporate life-style changes, such as regulation of sleep and eating habits, regular exercise, avoidance of identified triggering factors and stress management. Emphasis must be placed on preventive measures rather than on analgesic or abortive strategies. Stressing the reintegration of the patient into school and family activities and assessing prognosis are other issues to address during the first visit. There are limited data evaluating the outcome of CDH in children and adolescents.

Cranio. 2009 Apr;27(2):101-8.
Relationship of temporomandibular disorders to muscle tension-type headaches and a neuromuscular orthosis approach to treatment.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology of the State University of New York (SUNY) Stony Brook School of Dental Medicine, NY, USA. tmjbcooper@aol.com
A prominent etiological theory proposed for TMD related headache is that it results from a dysfunctional masticatory muscle system, wherein muscle hyperactivity is frequently caused by dental temporomandibular disharmony. The central goal of this article was to determine from a literature review of the subject whether there is significant evidence to support a relationship between headaches and TMD prevalence. A second purpose was to determine from such a review whether any relationship was one of cause and effect and whether treatment of the TMD condition can result in meaningful reduction or resolution of headaches. In the literature, there was a substantial amount of evidence for a positive relationship between TMD and the prevalence of headaches, and most importantly, that these were the muscle tension-type. Evidence for a cause and effect relationship was strong. It generally showed in numerous patients that TMD treatment of a large number of patients resulted in significant improvement in the physiological state of the masticatory system (muscles, joints and dental occlusion). Reduction or resolution of muscle tension-type headaches that were present was clinically significant. The authors concluded that TMD should be considered and explored as a possible causative factor when attempts are made to determine and resolve the cause of headaches in patients with this affliction. A benefit of resolving headaches at an early stage in their development is that it might result in the reduction of its potential for progression to a chronic and possibly migraine headache condition.

PMID: 19455921 [PubMed - indexed for MEDLINE]

Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.

Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. tmjbcooper@aol.com
Comment in:

Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.

PMID: 18468270 [PubMed - indexed for MEDLINE]

Labels: CDH, Chicago, ETTH, il, neuromuscular dentistry, TMJ