Dr. Shapira's Chicago Headache Blog

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

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

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

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


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

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

PMID: 20141363 [PubMed - in process]

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

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

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

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

Chronic pain is frequently multifactorial in nature. Neuromuscular dentistry has been very successful in treating TMD, Migrines, Tension Type headaches and other disorders. Frequently it is not a total cure but 50-80% reduction in pain is usually attained within several visits. There are many disorders and symptoms associated with TMD including:
Ear Aches or Otalgia
Sinus Pain
TM Joint Clicking and Popping
Ear Stuffiness or Eustacian Tube Dysfunction
Dizziness
Vertigo
Temporal Pain
Occipital Headaches
Morning Headaches
Sleep Apnea
Snoring
Sore Throats
Neck pain or stiffness
Feelings of a foriegn object in the throat
Pain in or behind the eyes
Scalp pain or feeling like your hair hurts

Most of these symptoms are mediated by the Trigeminal nerve and the Trigeminovaqscular system. These Nerves also connect to facial nerves, occipital nerves, glossopharyngeal nerves and to the autonomic nervous system. What happens in these nerves cause biochemical changes in the brain. Recent stuies shown the neural plasticity can create permanent changes in the brain. If chronic pain is the stimulus it can lead to central sensitization.

Changes inthe brain can be reversed over time but the exact amount of recovery will vary with individual patients genotypes, how long the pain has been present , other comorbidities that the patient carries. Some patients experience immediate3 and almost miraculous pain relief while others have a slower longer version of recovery. I always tell my patients to work for 50 - 80% improvement in pain. That is then our new starting point and we again seek 50 - *0 % reduction in pain.

There is "no cure" for long term chronic pain because lives have been changed due to living with pain. A cure would require a do-over of the years you had pain. There are no do-overs therefore we look to improve your future quality of life to the maximum. Some patients still have to do exercises or watch diet or even continue different medications. Other patients have remarkably and incredible improvements as described by Dr Barry Cooper in Cranio where he talked about "overwhelming success". This is why we use a diagnostic orthotic as the first step of treatment. We try to avoid permanent changes until the patient feels substantially improved. This is not a judgement that any doctor can make for the patient. It is a subjective evaluation by the patient themselves. Only the patient knows how well or poorly they are doing. We may have objective data showing physical improvement but the final test is have we improved or dramatically improved the patients quality of life. If the answer is yes we can talk about long term stabilization. The diagnostic orthotic is the first phase of treatment for those patients.

If the patient has improvement, whether it is only 25-30% or if they are at 80-90% the decision that the diagnostic orthotic treatment is successful remains the patient's. If they do not feel sufficiently improved they should not feel pressured into continuing treatment or making permanent changes. You should treat the diagnostic orthotic like a CAT SCAN or MRI but instead of images we have improvement in the quality of life. If improvement is not sufficient then a diagnostic approach should continue.

While NEUROMUSCULAR DENTISTRY IS REMARKABLY EFFECTIVE AT TREATING MANY CONDITIONS THERE ARE OTHER CONDITIONS THAT ARE NOT RELATED TO THE TRIGEMINAL NERVOUS SYSTEM, MYOFASCIAL PAIN OR JAW JOINTS.

TMJ disorders are frequently called The Great Imposter ("SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IS A MUST READ FOR ANY PATIENTS WITH MIGRAINES OR TMD http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor) but we must remember that other disorders can also masquerade or more frequently coexist with these problems. Many times a diagnostic orthotic relieves many of the symptoms but the remaining symptoms have a different cause. The expression that "you can't see the forest for the trees" applies. When the majority of symptoms are relieved you now find that you can identify a particular problem that was lost in a long and winding maze of symptoms. As NMD unravels the maze a specific problem can now be identified and treated.

Labels: chronic daily headaches, diagnostic orthotic, facial pain TMJ, Migraines, neuromuscular dentistry, neuromuscular dentistry tmd, neuromuscular orthotic, quality of life, TMJD

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

An article (PubMed abstract below) in Janury "CRANIO journal" by Dr Wes Shankland dicusses patients with anterior throat pain. These patients have frequently seen numerous physicians and had multiple digagnostic tests and frequently ineffective treatment. There are five syndromes that frequently cause this type of problems. The five disorders are, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome.

Ernest syndrome and Ernst Syndrome are caused by calcification of stylohyoid or stylomandibular ligaments that is frequently diagnosed by panoramic radiographs and palpation of the ligaments. There are numerous cases of throat pain being referred from various muscless but Dr Shankland points to the Superior Pharyngeal constictor syndrome.

According to an article from Tulane (see PUBMED abstract below) a diagnosis of Eagle's syndrome can be difficult to make. The diagnosis is infrequent and the symptoms vary widely.

An excellent description of Eagles Synrome can be found in "South Med J. 1998 Jan;91(1):43." (see PubMed abstract below) "Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear". Some of the symptoms of Eagle's Syndrome include:
Pain on turning head
Pain associated with tongue protrusion
Cough without sputum
Voice changes
Symptoms of Sinusitis that do not respon to treatment
Dizziness and/or feelings of disequilibrium, Vertigo
Bloodshot eyes
Throat pain,Throat discomfort Throat soreness or Foreign body sensation in throat
Facial pain
Difficulty swallowing or Dysphagia
Disturbed sense of taste
Headache especially if associated with swallowing
Sensation of excessive salivation
Swallowing difficulty, throat pain associated with swallowing
Pain on opening mouth

Bafaqeeh subclassified Eagle's syndrome into two different types: its classic form and an entity he called styloid-carotid artery syndrome. Symptoms include neurological and vascular problems with at least one report of blindness. The management of styloid-carotid artery syndrome include sagittal CT angiography and/or intraoperative neurophysiologic monitoring, and a transcervical approach to resection.

Many cases of undiagnosed throat pain respond well to neuromucular diagnostic orthotics. When the orthotic and/or trigger point injections do not relieve the pain these other conditions must be explored.


Cranio. 2010 Jan;28(1):50-9.
Anterior throat pain syndromes: causes for undiagnosed craniofacial pain.
Shankland WE 2nd.

TMJ & Facial Pain Center, Westerville, Columbus, Ohio, USA. drwes@drshankland.com
It is not uncommon for practitioners who treat craniofacial pain to see patients with undiagnosed throat and submandibular pain. Usually, these patients will already have been seen by their primary care physician and frequently, several others doctors including otolaryngologists, oral and maxillofacial surgeons, and even neurologists. Far too often these patients have three common features: 1. they have endured multiple expensive diagnostic tests; 2. they have received treatment of multiple courses of antibiotics; and 3. no specific diagnosis for their pain complaints has been determined and their pain persists. In this article, five disorders, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome are briefly described. All five produce common symptoms, making diagnosis difficult, which is often followed by ineffective or no treatment being provided to the patient. Diagnostic criteria and suggested treatment modalities are also presented.

PMID: 20158009 [PubMed - in process]

J La State Med Soc. 1992 Aug;144(8):343-5.
Eagle's syndrome: the Ochsner experience.
Weiss LS, Butcher RB, White JA.

Dept of Otolaryngology-Head & Neck Surgery, Tulane University Medical Center, New Orleans.
Eagle fully described the syndrome that bears his name in 1948. He noted that the typical patient had undergone tonsillectomy in the past. Although reported in the literature, the carotid artery syndrome is frequently overlooked in patients manifesting craniofacial or pharyngeal pain but who have not undergone tonsillectomy. Cases representative of the variety of patients with Eagle's syndrome treated at the Ochsner Clinic Department of Otolaryngology are presented. The diversity of symptoms and its rather uncommon occurrence often make the diagnosis of Eagle's syndrome elusive. The anatomy and embryology of the stylohyoid complex is discussed, as well as the symptoms, differential diagnosis, workup, and treatment of Eagle's syndrome. We hope to refamiliarize the clinician with this condition in order that it be considered in the assessment of patients with craniofacial pain.

PMID: 1453090 [PubMed - indexed for MEDLINE]

South Med J. 1997 Mar;90(3):331-4.
Eagle's syndrome (elongated styloid process)
Balbuena L Jr, Hayes D, Ramirez SG, Johnson R.

Otolaryngology-Head and Neck Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Tex, USA.
Comment in:

South Med J. 1998 Jan;91(1):43.
Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In adults, the styloid process is approximately 2.5 cm long, and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa. It may develop inflammatory changes or impinge on the adjacent arteries or sensory nerve endings, leading to the symptoms described. Diagnosis can usually be made on physical examination by digital palpation of the styloid process in the tonsillar fossa, which exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into the tonsillar fossa is highly suggestive of this diagnosis. Radiographic workup should include anterior-posterior and lateral skull films. The treatment of Eagle's syndrome is primarily surgical. The styloid process can be shortened through an intraoral or external approach. We present two cases and review the literature.

PMID: 9076308 [PubMed - indexed for MEDLINE]

Labels: eagles syndrome, Ernst syndrome, facial pain TMJ, headache with swallowing, neuromuscular dentistry tmd, pain with swallowing, sore throat, stloid ligament, styloid-carotid artery syndrome, Throat Pain

I have had an enormous respones from visitors to this website looking for a neuromuscular dentist and not finding one listed in their area. If you need help find a neuromuscular dentist we try our best to connect you with one.

I do ask for feedback on doctors because I do not know all of them personally. I am most happy when I can refer to an excellent clincian that I trust.

While I believe that neuromuscular dentistry is essential for a majority of patients it does not exclude many other varieties of treatment in conjunction with NMD.

Quality of Life is the name of the game. We want to help you on your journey to that better quality of life.

Labels: diagnostic orthotic, LVI, myotronics, neuromuscular dentistry, neuromuscular dentistry migraine, neuromuscular dentistry tmd, neuromuscular orthotic