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 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

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

Osteopathic manipulation and Chiropractic manipulation both treat headaches by changing input into the trigeminal nerve much like neuromuscular dentistry does. The article states: " Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache." The pathology in the neck is addressed to reduce pain (nociceptive) input into the trigeminal nucleus caudalis. The easiest and most direct method of reducing nociceptive input into the trigeminal nerve is a diagnostic orthotic followed by definitive long term treatment. The beauty of neuromuscular dentistry is that correcting the stomatognathic/ trigeminal system leads to auto correction of many neck problems.

The reason that NUCCA and A/O (atlas orthogonal) chiropractic is so effective when used in conjunction with a neuromuscular orthotic is that the chiropractic and/or osteopathic adjustments hold when the underlying masticatory pathology is adressed.



J Am Osteopath Assoc. 2007 Nov;107(10 Suppl 6):ES10-6.
Diagnosing and managing migraine headache.
Mueller LL.

University Headache Center, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, 42 E Laurel Rd, University Doctors Pavilion, Ste 1700, Stratford, NJ 08084-1354, USA. SOMPhysicians@umdnj.edu
Comment in:

J Am Osteopath Assoc. 2008 Apr;108(4):191; author reply 191, 214.
Headache is one of the chief complaints among patients visiting primary care physicians. Diagnosis begins with exclusion of secondary causes for headache. More than 90% of patients will have a primary-type headache, so diagnosis can often be completed without further testing. Although tension-type headaches are the most common kind of headache, patients with this type of headache rarely seek treatment unless occurrence is daily. Migraine, which affects more than 30 million people in the United States, is the most common headache diagnosis for which patients seek treatment. Migraine is a chronic, often inherited condition involving brain hypersensitivity and a lowered threshold for trigeminal-vascular activation. Intermittent debilitating attacks are characterized by autonomic, gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease in a patient's quality of life, as measured by physical, mental, and social health-related instruments. Accurate assessment of a patient's disability will guide physicians in prescribing appropriate modes of therapy. However, migraine remains underdiagnosed, and patients with migraine remain undertreated. A comprehensive treatment approach to migraine may include nonpharmacologic measures, as well as abortive and prophylactic medications. Informing patients about realistic treatment expectations, possible delayed efficacy of medications, and avoidance of caffeine and overuse of medications is critical for successful outcomes. Management of migraine is a dynamic process, because headaches evolve over time and medication tachyphylaxis may occur, necessitating changes in therapy. Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache.

PMID: 17986672 [PubMed - indexed for MEDLINE]

Labels: A/O, atlas orthogonal, atypical migraine, cluster headache treatment, Migraines, neuromuscualr dentistry, NUCCA, nucleus caudalis, spenopalatine block TMJ, TMD, trigeminal nerve

Check out my dental website for additional information on Neuromuscular Dentistry

http://www.delanydentalcare.com/neuromuscular.html

Labels: 60031, cluster headache treatment, Gurnee, headache specialist, Lake Forest, Migraines, neuromuscular dentistry, spenopalatine block TMJ, TMD, TMJ Specialist

There was an excellent article in Practical Pain Management by Edwin A Ernst III DMD on Temporal Tendinitis. Common pain reference sites (according to the article) for this condition include: Painful TM Joints (Temporomandibular joint or TMJ), Ear Pain and/or stuffiness in the ear, retro-orbital pain sometimes radiating to occiput and /or shoulder, upper and lower aching teeth, pain in or around the eye, pain in the lateral temple area, and occasionally pain in the area of the stylomandibular ligament. These pains are frequently accompanied by prodromal symptoms similar to migraine of Nausea, vomiting, photophobia and visual disturbances.

This can be extremely intense pain and is frequently initiated by trauma such as an auto accident. Many patients with this disorder can have trouble fitting their back teeth together. The pain can be unilateral or bilateral and patients will frequently use analgesics, opiods or visit hospital ER's because of the pain severity. Physicians rarely palpate the coronoid tendon therefore these patients are easily misdiagnosed. Intra-oral palpation is essential in the diagnostic process and most physicians are not trained in palpation of these important structures. Dr Ernst coined the phrase "The Migraine Mimic " in 1983 but many physicians are not familiar with craniofacial pain literature.

The actual problem is a tendenosis of the temporal tendon at the tip of the coronoid process. Increasing the pressure of palpation causes increases in the level of the pain. If a Migraine Mimic headache is evoked use of lidocaine diagnostic injection should lessen or alleviete the pain.

Treatment with local anesthetic and Sarapin and/or Steroid is recommended by Dr Ernst and if this is not curative he recommends radio-frequency thermoneurolysis. I have never found this to be necessary and prefer to try prolotherapy as a first line treatment and if that is not effective then utilize a steroid. If the pain is exquisitely acute than beginning with steroid may be advantageous.

Temporal tendinitis can also be found in chronic muscle disorder from chronic pathology but is usually significantly less intense. Patients can suffer for years with this condition and be treated for migraines with poor results and no long term resolution.

I still recommend correction of the neuromuscular position of the mandible with a diagnostic orthotic even when temporla tendinitis is diagnosed. If total relief is achieved a reevaluation of baseline jaw position is recommended before phase 2 therapy.

Labels: diagnostic block.coronoid tendon, Edwin Ernst DMD, ILlinois, Migraine mimic, palpation coronoid tendon Chicago, prolotherapy, temporal tendinitis, Temporomandibular disorder, The Great Imposter, TMD, TMJ

The Sphenopalatine ganglion block can be used to prevent and/or relieve headaches and Migraines. I have used it for many years in my office as an adjunct for treating headaches and migraines in patients. While it is not effective for all patients there is a subgroup that remarkable relief from pain and a second group that can stop a migraine before it becomes full blown.

The real beauty of SPG blocks is that they are simple and safe and I teach patients how to use them at home when they need them. The block is done with a Q-tip with lidocaine. The q-tip is gently place in the nostril until the lidocaine soaked cotton tip is adjacent to the SPG. This is left in place for 20-30 minutes. It ia also effective for some patients with cluster headaches and sinus headaches. The results for some patients are miraculous while other patients have minimal change in symptoms. Some patients who do not get relief from the SPG block can prevent migraines and chronic daily headache by regular use a a preventitve agent.

This uses only lidocaine and is extremely minimal to no risk if there is not a lidocaine allergy.

This is not replacement for treating the underlying causes of the pain with a neuromuscular orthotic but is a great adjunct durng treatment and for those patients who do not get complete relief.

Labels: cluster headache treatment, migraine treatment SPG, neuromuscular dentistry, spenopalatine block TMJ, Spenopalatine ganglion block headaches, TMD, TMJ

Patients with morning headaches usually have either TMJ disorders or Sleep Apnea. Sleep Apnea can be treated with CPAP or an Oral Appliance. Patients who have TM Joint clicking and are undergoing treatment for headaches or TMD can benefit in several ways from having a night-time apnea appliance and a daytime neuromuscular orthotic.

A problem that is sometimes encountered with oral appliances for sleep apnea are undesired bite changes. These changes can actually be helpful when treating TMJ clicking and popping and headaches. The bite changes that occur are actuallly the healing of the TM Joint. The jaw usually postures forward unloadding the retrodiscal lamina of the TM Joint that is compressed in patients with clicking. The retrodiscal lamina rehydrates and does not let the condyle go into retrusive pathology which serves to stabilize the disk.

The Daytime appliance allows this position to stabilize and heal. In patients who are not undergoing treatment exercises are done to prevent this healing from occuring. The joints will frequently heal if placed in a healthy position. A recent paper showed no damage to the joints with sleep appliances.

The American Academy of Sleep Medicine recommends that dentists fitting patients with oral appliances for sleep apnea be well versed in treating TMJ disorders. There are many good reasons for this recomendation. Dentists who do not uderstand how bite changes affect the joints and the muscles as well as head posture can create difficult problems they do not have the expertise to treat. Please check my I HATE CPAP website (http://www.ihatecpap.com) for more information about the dangers of sleep apnea and on how oral appliances are used in treating sleep apnea.

Labels: AASM, American Academy of Sleep Medicine, bite Changes, cluster headaches, headaches, neck pain, SLEEP APNEA, TMD, TMJ, TMJ clicking, TMJ pain, TMJ popping, TMJD

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

I just saw a patient today that I treated a few years ago. Shae had had over 25 years of severe TM Joint pain and Headaches. She was referred to me by an Oral Surgeon in Texas. This patient had worn an oral appliance continuously for years with only partial pain relief.

A diagnostic neuromuscular orthotic and trigger point injections had led to complete pain relierf and she opted for a cosmetic dental reconstruction as she was anxius to no longer wear an appliance. It has been several years since the reconstruction and though she mad a couple of appointments she would always cancel before she camein.

I saw her today, still free of jaw pain and headaches because she had chipped two anterior veneers and had stayed away because she was worried about cost. In the last year her husband and her bought a new house and he lost his job. They now had two mortgages to pay and she needed emergency surgery. There are some personal family problems that are upsetting and a few other crisis. There was no return of the chronic jaw pain and/or headaches in spite of the stress. She had broken her oral appliance that treatwed her sleep apnea as well and that was when she chipped the teetth.

It turns out the chips in the porcelain were minimal and just needed smoothing. She will be receiving a new sleep apnea appliance very soon which will also prevent her from chipping her teeth.

After a lifetime of chronic pain her neuromuscular dentistry kept her comfortable even while under some of the worst stress in her life. Luckily her husband is now working again at a better job and they rented the second house so they are no longer stuck with two mortgages.

Labels: headaches, ILlinois, neuromuscular dentistry, TMD, TMJ

A new study in Anaesthesia Progress reported on a new method to treat dislocation of the Temporomandibular Joint (TMJ or TM Joint). The technique is to do a deep temporal nerve block with lidocaine to reduce muscle spasm The entire study "Use of Masserteric and Deep Temporoal Nerve Blocks for Reduction of Mandibular Dislocation" is available at www.anaesthesiaprogress.org.

An alternative method that I frequently use for patients is to induce instantaneous muscle relaxation of elevator muscles via a gag reflex. This will frequently cause an immediate reduction of an acute close lock dislocation.

Labels: dislocation, temporomandibular joint, TM Joint, TMD, TMJ

Neuromuscular Dentistry frequently eliminates not just headaches and Migranes but vertigo and dizzinss as well. There are many possible ways in which this occurs based on neurological changes in the trigeminal nervous system and the connections to other cranial nerves. The following is an anatomical explanation of how neuromuscular dentistry treats Vertigo. Other causes can include the Tensor tympani and Tensor palati causing increase in pressure in the inner ear creating endolymph movement in the semi-circular canals, Tensor typani and palati influenced by postural anomolies to contract and relax in an imbalanced way, th Head of the condyle seated posteriorly putting pressure on the inner ear, and the Misalignment of Atlas - Axis - Occiput and resulting compression on the balance centre in the brainstem

Patients with TMJ disorders frequently suffer from dizziness and verigo as well as migraines, tension-type headaches, facial pain and many other symptoms usually associate with the trigeminal nervous system and secondary postural canges in the atlas, axis and other cervical vertebrae. The term "The great Imposter" (See "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR" in Sleep and Health Journal http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor)
is often applied to TMJ disorders because they masquerade as so many disorders. The following is an anatomical description by Dr Norman Thomas, the head of Neuromuscular Dental Research at LVI (Las Vegas Institute) research of how imbalance of the HIP plane can result in Vertigo thru actions on the Tensor Tympani and and Tensor Palatini muscles.

Per Dr Thomas "You asked for the explanation I put forward about HIP tinnitus and vertigo. The tensor tympani and tensor palati muscles intertwine as they associate at the side of the bony canal of the pharyngo tympanic tube. The entwined fibers pass downward from their attachment in the scaphoid fossa over the hamular notch into the soft palate. Thus the attachment of tensor typani and palati crosses the fulcrum at the hamular notch between IP and the occipital condyle. When the HIP is this not balanced with gravitational field there is tension on the the palate and the tensor tympani (attached at its distal end to the malleus) while the tensor palati closes the Eustachian tube opening at its palatal end Thus there is pressure in the middle ear which compresses the fenestra ovalis on the medial wall of the middle ear to change circua;lation in the semicircular canals with resulting vertigo and tinnitus."

THE HIP Plane as described in the Journal of Oral Rehabilitation is "The HIP occlusal plane is a horizontal plane passing through the bilateral hamular notches and the incisive papilla (Dent Surv. 1975;51:60)" Other planes of clinical interest in the cranium and face include the he occlusal plane, Frankfort plane, Camper's plane. The hip plane is parallel to the gravitational field.


PubMed abstract
J Oral Rehabil. 2007 Feb;34(2):136-40.
Three-dimensional analysis of the occlusal plane related to the hamular-incisive-papilla occlusal plane in young adults.
Fu PS, Hung CC, Hong JM, Wang JC.

Department of Prosthodontics, Graduate Institute of Dental Science, Kaohsiung Medical University, Kaohsiung, Taiwan.
The planes which serve as references for cranium and face in dental clinical application included the occlusal plane, Frankfort plane, Camper's plane and hamular-incisive-papilla (HIP) plane. The HIP occlusal plane is a horizontal plane passing through the bilateral hamular notches and the incisive papilla (Dent Surv. 1975;51:60). The aim of this study was to estimate the relationship between the various occlusal planes and the HIP plane in Taiwanese young adults with approximately optimal occlusion. Study casts of 100 young adults (50 men and 50 women) were selected in this study. All market points on the maxillary casts were measured by a three-dimensional precise measuring device. The angular relationship between the four various occlusal planes and the HIP plane were investigated. The vertical distances between the cusp tips and incisal edges of maxillary teeth to the HIP plane were measured. Data were performed by the Statistic analysis software programme (JMP 4.02). The Student's t-test and Pearson's correlation test were used to test the statistical significance (P < 0.05). The results showed that the occlusal plane defined as the incisal edge of maxillary central incisor to mesiobuccal cusp tips of maxillary second molars had the smallest included angle with the HIP plane (2.61 +/- 0.81 degrees). The incisal edge of maxillary right central incisal to mesiopalatal cusp tips of maxillary first molars had the largest included angle with the HIP plane (7.72 +/- 1.60 degrees). The curve is drawn through the buccal cusp tips of maxillary teeth had better parallelism with the HIP plane.

PMID: 17244236 [PubMed - indexed for MEDLINE]

Labels: neuromuscular dentistry, TMD, TMJ, verigo, vertigo treatment

When you see a doctor for the first time for a TMJ disorder you should expect to have to give lengthy and detailed history. There are usually forms to fill out. What is important is that this history should be reviewed with the patient and how the history relates to the current problem should be explored. The initial consult is usually at least 45 minutes but can last for several hours.

In most cases the doctor can provide instant relief of some of the painful conditions by deactivating muscular trigger points. This is usually done by use of a technique called Spray and Stretch that utilizes a vapocoolant spray. These techniques were developed by President Kennedy's personal physician Dr Janet Travell. In most patients it is possible to connect their symptoms to their history in an understandable fashion.

If there is a acute close-lock of the TM Joint time is of the essence and immediate reduction is best if possible. Prescribing anti-inflamatories should never take the place of attempting to reduce an acute disc dislocation.

Permanent and/or irreversible treatment should rarely be the initial treatment. Adjusting the teeth or doing equilibration of the back teeth should be avoided when there s acute muscle spasm. The exception is if a recently placed restoration is in hyperocclusion and percipitated the problem. It should be carefully evaluated because acute spasm can change the bite.

A thorough examination of the muscles and joints is usually performed before initiating treatment. A Neuromuscular Dentist will usually take impressions and a bite utilizing TENS (transcutaneous electrical neuro stimulation) as well as EMG and computerized mandibular scans. This information helps the dentist understand all aspects of the problem before initiating treatment.

Many insurance companies deny coverage of TMJ disorders and Neuromuscular diagnostic work-ups. This is done to "save money" but in reality it has a heavy toll in the quality of patients lives and their future health and welfare. Insurance companies are not in the business of caring for patients. Insurance companies are in business to make money for their shareholders. The larger the premiums they collect and the less they pay in benefits the better the bottom line. A healthy bottom line is the primary concern of insurance companies. These companies are in business to creat profit and shareholder value. The executive of insurance companies make millions of dollars in bonuses for increasing profitability. Unfortunately for patients increasing profitability usally is done by denying patients medical benefits. The more effective an insurance company is in reducing payments for care the more profitable they become.

The insurance companies often use terms such as reasonable and customary to explain why patients are not given the coverage they were promised. I have been treating sleep apnea with oral appliances for close to 30 years. In the early years I was the only dentist in the state of Illinois doing this type of treatment. I would still receive letters telling me my fees were more than "usual and customary" even though I was the only doctor doing these treatments.

Labels: insuranceTMJ treatment, TMD, TMJ, TMJ Specialist, TMJD

There is an very cool trick that can be used to provide instant relief for some migraines and tesion-type headaches. Because most headaches are trigeminal in orgin stimulation of the GAG reflex will often alleviate both headaches from muscle spasm and/or myofascial pain. The gag reflex is a protective reflex that prevents aspiration of vomit into the lungs by rapid wide opening of the mouth.

The GAG reflex causes the elevators of the mandible (mouth closing muscles) to instantly relax completely and the suprahyoid and infrahyoid muscles that are depressors of the mandible (mouth opening muscles) instantly contract. This causes a mouth opening like a snake as oposed to a normal hinge opening. If a patient has a tension-type headache,ETTH, chronic daily headache or muscle contraction headache from the jaw muscles they will frequently have complete or very significant headache relief. This same technique can also be used to reduce an acute close lock (joint locking that prevents opening) of the mandible.

Migraine headaches can also be turned off or sometimes prevented if this proceedure is done before a full migraine occurs. The mechanism is both reduction of muscle pain which is a significant portion of most migraines but also a change in the circulation to the anterior 2/3 rds of the meninges of the brain. The trigeminal nerve controls that blood flow and a forceful gag will often correct the vascular cause of the migraine thru trigeminal nerve changes. This can also be used by patients who do not have access to their headache medication.

It is very important to keep the teeth from touching after stimulating the gag reflex to prevent a return of the headache.

Many physicians and patients consider nauseau and vomiting associated with headaches to be diagnostic of migraines but this is not always the case. TMJ and muscle caused headaches frequently are associated with nauseau.

Patients who have migraines that are relieved after vomiting should consider the trigeminal nerve and its related muscles as a cause of their headaches. Neuromuscular Dentistry can frequently supply long-lasting relief for these patients. The gag reflex is a remedial maneuver that can relieve a severe headache but long-term improvement in the quality of life can be achieved for many patients by utilizing a diagnostic neuromuscular orthotic. If substantial relief is achieved the patient can the consider a long term correction based on the position of the jaw when wearing the orthotic.

Labels: atypical migraine, Gag reflex, neuromuscular dentistry, TMD, vomiting

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

THIS IS AN INTERESTING ABSTRACT ON TREATMENT OF ANKYLOSING SPONDYLITIS AND TMD TREATMENT COMBINED

I have a patient who we treated many years ago with neuromuscular dentistry who had ankylosing Spondylitis as did his father. We started with a diagnostic work-up that included EMG and MKG and use of ULF TENS to relax trigeminally innervated muscles and created a dianostic orthotic. The patient finished his case orthodntically and has been stable for close to 20 years. The Ankylosing spondylitis resolved (Was this because of neuromuscular dental treatment or an incidental occurence?)

The patient firmly believes the neuromuscular dentistry "saved him" He later married and we treated his wife for severe headaches and vertigo again using neuromuscular dentistry. Her treatment included implants and overdentures but began with a diagnostic orthotic.

The neuromuscular diagnostic orthotic is an essential element in treating TMJ disorders, migraines and Tension Type headaches. After determination of the patients initial condition thru use of EMG (bipolar skin electrodes) MKG (mandibular kinesiograph) or computerized mandibular scan, ULF TENS a neuromuscular bite registration is taken to build the diagnostic orthotic. The orthotic is not 'perfect" at delivery but must be continually adjusted to account for changes in the patients posture and physiology. When the patient is stabilized it is necessary to reevaluate whether the desired results have been obtained ie; relief of headaches, ear pain , joint pain, sinus pain , clicking , locking , migraines or other symptoms. If the patient feels substantial improvement they can opt for a second phase of treatment for long term relief. This can be a cast removable orthotic, Crown and/or bridge reconstruction, implants, orthodontics or jaw surgery. If substantial improvement is not seen non-reversible treatment should be avoided. Sometimes irreversible treatment can be provided but expectations for relief should be minimal if orthotic treatment is not successful. I suggest "Patient Beware" , ask lots of questions and proceed with caution.

Contrast the Neuromuscular Dental approach to the CR or Centric Relation approach that often begins with equilibration (permanent changes to teeth and occlusion) as the first step or treatment. The position is often based on the concept of Bimanual Manipulation. This means that the dentist uses his hand muscles to determine the proper jaw position by manipulating the jaw. This has also been caused "Romancing the mandible" Barney Jankelson the Father of Neuromuscular Dentistry felt that romancing the mandible was a concept that would fall to the wayside when scientific instruments could be used to measure where and how the muscles and joints functioned with physiologic ideals. His famous quote "If it is measured it is a fact , otherwise it is an opinion " described why he felt the old concept of Centric Relation had outlived it usefullness. There have actually been at least 26 different definitions of CR as proponents tried to define an appropriate position for the joint.

Neuromuscular Dentistry is more concerned with creating a healthy condition where the muscles and neuromuscular bite auto-position the condyle of the TM Joint in the proper position.

Publication: World Journal of Orthodontics Winter 2009 Volume 10 , Issue 4

Ankylosing Spondylitis Associated With Craniomandibular Disorder—A Combined Orthodontic And Prosthodontic Therapeutic Approach
Petros T. Koidis, DDS, MS, PhD/Ioanna Basli, DDS/Nikos Topouzelis, DDS, PhD
Ankylosing spondylitis is a disease that causes inflammatory changes of the involved joints. Although the initial clinical signs are pain and discomfort, synovial changes progressively involve all the axial joints, including the temporomandibular joint (TMJ). Eventually, bony alterations develop (condylar erosions, flattening, sclerosis) that affect the position of the condyle, the superior joint space, and the range of movements. These symptoms correlate with the severity of the disease. Besides physiotherapy and surgery, no dental rehabilitation has been reported for these patients. This report of a female patient with ankylosing spondylitis and a TMJ disorder emphasizes dental rehabilitation. The aim of the splint, orthodontic, and prosthodontic treatment was to relieve the subjective symptoms through establishing a stable optimum occlusion. Anamnestic, laboratory, and clinical findings including pre- and postradiographic examination records are presented. World J Orthod 2009;10:371–377.

Labels: Centric Relation, CR, neuromuscular dentistry, TMD, TMJ

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

An article from Johns Hopkins School of Medicine evaluated TMD patients relative to sleep disorders and pain sensitivity. The study found two or more sleep disorders in 43% of patients. Insomnia and sleep bruxism were the two most commonly found sleep disorders. Both Primary Insomnias (PI) and Respiratory Disturbance Index (RDI) were associated with increased pain sensitivity.

The authors concluded Primary Insomnia and Sleep Apnea were at such high rates that any TMD patients complaining of sleep distubances should be rferred for polysomnography (sleep test). They also felt that Primary Insomnia was highly associate with hyperalgesia and may be linked to the onset of central sensitivity and be the underlying etiology in idiopathic pain disorders. The authors also stated "The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes."

The NHLBI has previously published a report "Cardiovascular and Sleep Related Consequences of Temporomandibular Disorders" Which details the numerous problems related to TMD problems. The majority of problems are related to sleep apnea (http://www.ihatecpap.com/sleep_apnea_dangers.html) and to disturbances in the trigeminal nervous system and the trigeminal vascular effects.

It is becoming more apparent that TMJ joint pain and headaches related to TMD are only the tip of the iceberg. Correction of the neuromuscular function of the stomatognathic system could lead to widespread improvements in health and function in sites often not associated with TMD problems. An excellent article on neuromuscular dentistry can be found in Sleep and Health Journal at http://www.sleepandhealth.com/neuromuscular-dentistry.

PubMed abstract below:
Sleep. 2009 Jun 1;32(6):779-90.
Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder.
Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA.

Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA. msmith62@jhmi.edu
STUDY OBJECTIVES: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity. DESIGN: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold. SETTING: Orofacial pain clinic and inpatient sleep research facility. PARTICIPANTS: Fifty-three patients meeting research diagnostic criteria for myofascial TMD. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05). CONCLUSIONS: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.

PMID: 19544755 [PubMed - indexed for MEDLINE]

Labels: facial pain, Idiopathic pain, neuromuscular dentistry, sleep disorders, TMD, TMJ, TMJ Specialist

A recent paper in the Journal of Complementary Medicine in December 28, 2009 evaluate the acupuncture for treating TMD symptoms. They evaluated four previous randomized controlled studies that all showed statistically significant improvement in symptoms "in relation to short-term improvement of TMD signs and symptoms of a muscular origin". The authors concluded "research into the long-term effects of acupuncture in the treatment of TMD is needed" The PubMed abstract is listed below for your convenience.

J Altern Complement Med. 2009 Dec 28. [Epub ahead of print]
Effectiveness of Acupuncture in the Treatment of Temporomandibular Disorders of Muscular Origin: A Systematic Review of the Last Decade.
La Touche R, Angulo-Díaz-Parreño S, de-la-Hoz JL, Fernández-Carnero J, Ge HY, Linares MT, Mesa J, Sánchez-Gutiérrez J.

1 Program in Orofacial Pain and Craniomandibular Disorders, San Pablo CEU University , Madrid, Spain .
Abstract Objective: The purpose of this review is to evaluate the effectiveness of using acupuncture treatment for temporomandibular disorders (TMD) of muscular origin according to research published in the last decade. Methods: The information was gathered using the MEDLINE, EMBASE, CINAHL, and CISCOM databases. The inclusion criteria for selecting the studies were the following: (1) only randomized controlled trials (RCTs) were selected; (2) studies had to be carried out on patients with TMD of muscular origin; (3) studies had to use acupuncture treatment; and (4) studies had to be published in scientific journals between 1997 and 2008. Two (2) independent reviewers analyzed the methodological quality of the studies using the Delphi list. A total of four RCTs were chosen once the methodological quality was judged as being acceptable. All of the studies included in the review compared the acupuncture treatment with a placebo treatment. All of them described results that were statistically significant in relation to short-term improvement of TMD signs and symptoms of a muscular origin, except one of the analyzed studies that found no significant difference between acupuncture and sham acupuncture. Conclusions:In the authors' opinion, research into the long-term effects of acupuncture in the treatment of TMD is needed. We also recommend larger samples sizes for future studies, so the results will be more reliable.

PMID: 20038262 [PubMed - as supplied by publisher]

Labels: Acupuncture, muscle pain, research, TMD, TMD treatment, TMJ

Blues Freak comments : I have cluster headaces for 8 plus yrs. I wore a TMJ piece nite and day for 2 yrs with no relief. Oxygen for almost a yr. even accuputcunter for over a yr. with a small amount for a short time. I don't work any longer I'm 56 on disabilty now. I need help

Dear Blues Freak,

When you say you are using oxygen I assume that is during an acute attack.. Oxygen (100%) can usually stop a cluster in its tracks. I understand that you wore a "TMJ mouthpiece" but all appliances are not the same. Some appliances are designed to effect primarily the jaw joint (TMJ) rather than address the neuromuscular problems that caused the joint problems. I call some appliances POPs which stands for Piece of Plastic. What is important is not the piece of plastic but how that piece of plastic how it functions. Some TMJ appliances ever do more than act a as a POP. TMD is Temporomandibular Dysfunction which includes muscles and joints. It is often necessary to evaluate the joints connecting the head to the first to vertebrae of the spine. The brain stem passes thru this area and these have an enormous effect on jaw relations as well as the entire nervous system. Atlas Orthogonal and NUCCA are two chiropractic groups that work with this area of the body.

I prefer the term orthotic or orthopedic appliance but what is important is what affect it is having on the body. In neuromuscular dentistry treatment starts with relaxing the muscles by pulsing the trigeminal nerves to create muscle relaxation but more importantly we then use the relaxed position to set the orthotic for minimal adaptation. This allowa the trigeninal nerve and the associated vascular effects to stabilize. http://www.sleepandhealth.com/neuromuscular-dentistry contains an explanation of how neuromuscular dentisty functions.

With cluster headaches it is possible initially to provoke a cluster headache so I would advise if oxygen relieves your pain to make sure the office is equipped with oxygen if needed.

Labels: cluster headaches, neuromuscular dentistry, oxygen, TMD, TMJ

Slightly rewritten from an LVI forum post explaining to new neuromuscular dentists the importance of body posture and a few of the ways t can be addressed.

I had the supreme honor of studying with Janet Travell and watched her magically turn long legs into short legs and vice-versa. A trick I picked up from her 30 years ago was to correct the standing leg posture, have the patient walk and correct it again. I use paper towels as temporary orthotics in the shoe. I have the patient take short walks and the readjust the foot orthotic (paper towel). It is done easily by feeling the top of he hips with your finger tips and getting them at eye level (patients love having their doc on his knees) after several adjustments it will stabilize.

I take most of my bites standing so I will do this before taking bite or adj. The bite is essential but is not just a record of upper jaw to lower jaw, but rather a way to capture 3 dimensional body mechanics and jaw relatin simultaneously.

I teach the patient how to do this at home. They need a full length mirror and two marker spots on the top of the hip bone. They stand 4-5 feet back from the mirror and hang a black plumb line in the middle of the mirror and can self adj.their orthotics. Initially they will do this several times a day. I Rx they just buy several diffent Dr Scholl pads an self adj frequently. Sometimes the lift will switch sides more than once while the spine staightens itself.

The second trick is to also check the hip height in the sitting position. We use tushy orthotics to even height of hips sitting. It is crucial to know if the high side changes from sitting to standing because it corkscrews the spine and wreaks havoc on the bite. These are the patients whose Atlas is never stable. We send them for Atlas orthogonal adjustment with a leg correction, We have the leg length checked standing before they leave because it may need a change in the orthotic and we check the sitting orthotic because they are sitting in the car going from one office to the other. We frequently have them keep an aqualizer in their mouth or a coton roll as well so we get a/o aj without having it affected by the bite. It would be a whole lot easier if we could just cut the head off and just deal with the bite.

The patient does the same proceedure with the plumb line but sits on a hard flat chair. The patients keep their tushy orthotics in their car, desk chair, couch etc. For long term correction of structural hip deficiecy I have had patients, usually women have them made from bike pants that the pads are adjusted and "tummy control"

If a patient has a structurally short hip on one side sitting and leg length discrepancy on the other we are guaranteeing long term problems and dental failures in the mouth.

It is vital patients do their ascending correction 24/7 or it is the same effect of our orthotics not being left in. Corrections must be continuous.

When I have a patient and we do the pen test (I use cotton rolls easier to adj to improve results) we show them arm strength and balance with the correction then without. I then correct leg length with something under shoe and repeat the test. They get the same results. We then do a double correction to increae strength and balance more and the we blow them away because they lose strength and balance regardless if we take away the shoe lift or the bite correction. They now completely understand ascending/descending concepts.

Now all we have to worry abut is the AP position of spine from hips to head including pelvic tilt and hip rotation and balancing pecs and rhomboids and the effects on jaw relation.

Labels: A/O, neuromuscular dentistry, NUCCA, posture, TMD, TMJ

i read your article and found it enjoyable. i can empathize with mary and joyce; losing track of medications which only work to a moderate degree, and seeing countless practitioners. it can be discouraging.

i often say TMD should be reworked into its own field of dental neurology. people with our symptoms very often slip through the cracks between medicine and dentistry. too often my neurologist would say, i don't know, i am not a dentist. conversely, the dentists said, i am not a neurologist. i wonder if medical school and dental schools are doing more to bridge this gap scholastically....

Labels: discouraging, headaches, neurology, neuromuscular dentistry, TMD

thank you very much for replying.

my family dentist told me i was grinding at night. i had no pain or obvious problems, so i told him to forget it, but he kept insisting. he made me a night guard which looked like a retainer i wore in 7th grade after i had braces. he instructed me to wear it at night, and if i was stressed to wear it during the day.

i wore it from march of 08 and my pain started in august of 08. as a result, i have an anterior open bite. i was told my molars supra erupted because the night guard kept them apart. i was also the the night guard is what *caused* this entire cycle because it loaded my joints and opened my bite.

the orthotic does not control my facial pain. i have tingling in my cheeks, aching, and forehead and scalp aching. my jaw feels tired and has total loss of proprioception.

it does not make sense to me that TMJ can cause the above facial symptoms. do you have other patients with symptoms like mine?

how does one regain the space lost between the condyle and fossa?

Reply
I have seen hundreds of patients with similar symptoms. TMJ disorders are often caused the Great Imposter because so many iverse problems can result. Check out this link for a story I wrote for Sleep and Health.
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor
Did the pain come on sudely or very gradually?
Normally you will not have a lot of supereruption from wearing an appliance only at night? If there is an acute dislocation of the disk it can create problems like you are having.
Do you have a problem opening your mouth wide as that is often seen with acute dislocation.?

Labels: anterior open bite, facial pain, nightguard, TMD, TMJ

comments : i wore an anterior nightguard which changed my bite. i now have an open bite. only one molar touches down. a few months into wearing this night guard, i had a sudden onset of excruciating tooth pain which started on one side of my teeth and spread to the other side within one week. the nerves in my face were also affected as my cheeks ache and also my forehead and scalp. my neuro says i do not have TN but my nerves are irritated. the only thing which helped was a lower mandibular splint. it took my teeth pain away within a few weeks however my bite is still open when i do not wear it. what do i do next? how do i take the pain away for good? can a bite change cause al this face pain? i never get headaches, only facial and tooth pain. my TMJ joints are only 4mm, and were pushed up and back into the upper part of my skull. the discs are both displaced. i have no space left in between either joint and the upper part of my skull. i am on an anti convulsant, and an anti
depressant for pain control, it is helping somewhat. please advise. Kristin

Labels: facial pain, neuromuscular dentistry, TMD, TMJ, tooth pain