Dr. Shapira's Chicago Headache Blog

It is an intresthing phenomenon that medication overuse headaches are an enormous problem in neuromuscular dentistry even though most neuromuscular dentists use very little medication. By the time patients have been seen by a neuromuscular dentist they have frequently seen numerous physicians and other medical specialists and are using multiple perscription and over the counter medications.

Breaking the cycle of medication overuse headache by STEWART J. TEPPER, MD in the Cleveland Clinic Journal of Medicine reported:

"(Abstract) When patients who have frequent, disabling migraines take medications to relieve their symptoms, they run the risk that the attacks will increase in frequency to daily or near-daily as a rebound effect comes into play. This pattern, called medication overuse headache, is more likely to happen with butalbital and opioids than with migraine-specific drugs, as partial responses lead to recurrence, repeat dosing, and, eventually, overuse. Breaking the cycle involves weaning the patient from the overused medications, setting up a preventive regimen, and setting strict limits on the use of medications to relieve acute symptoms."

Medication overuse headaches are a frequent event with neuromuscular problems that frequently caue chronic daily tension headaches. These medications to not correct the underlying problem and the paient now has a layer cake of headaches that are often frosted with vascular headaches. The tirgeminal nervous system and the related trigeminovascular system is primarily responsible for the majority of headaches. I frequently find weaning my patients off narcotic and pschoactive medications is much harder than eliminating their pain. This is especially true because I advise patients to follow their physicians guidance when weaning off medication. Physicians who have heavily prescribe drugs are not always the best influence to convince patients that overuse headaches are a problem.

Many patients who suffer from medication overuse headaches originally had either migraines, tension-type headaches or a combination of headaches. They frequently also have anxiety and depression as comorbidities. Chronic daily headaches usualy is defined by 3 months with over 15 days/month of headaches that last 4 or more hours if not treated with medication.

According to Dr Tepper "In a large population-based study,3 2.5% of patients who began with episodic migraine (headaches on fewer than 15 days per month) had “transformed migraine” (headaches on 15 or more days per month) 1 year later. The prevalence of chronic daily headache is almost 5% of the general population and may account for up to 70% of the initial diagnoses seen in headache centers." This is what I would call iatrogenic medicine where the treatment of episodic migraine can result in the development of transformed migraine. What is probably more common is that patients with headaches due to nociceptive trigeminal impulses which create migraine and Episoic Tension-Type Headaches are treated with medication rather than correction of the root causes of the headache.

Treatment of headaches must always consider the time of day when headaches occur. Morning headaches are almost universally a result of sleep apnea and/or trigeminal headaches as a result of TMJ disorders and clenching, grinding or other parafunction. The NHLBI considers sleep apnea to be a TMJ disorder so almost 100% of morning headaches are related to abnormal jaw and trigeminal nervous system input.

Denture Patients with morning headachjes represent a special population that may have an easy solution. Historically, dentists have told patients to sleep with their dentures out. this has been shown to cause drastic increases in sleep apnea (and probably morning headaches). Wearing dentures may not only relieve headaches, neck pain and sleep apnea but also help avoid heart attacks, strokes and memory loss. Denture patients with chronic head and neck pain should seek out a neuromuscular dentist who can idealize the physiology of the masticatory system. When patients wear dentures to long without replacement or refitting they may be prone to neck pain and cervicogenic headaches due to changes in head posture.

Dr Tepper describes medication overuse headaches as follow: "Medication overuse headache is a subset of chronic daily headache, also occurring on 15 or more days per month but with the added criterion of medication overuse, ie, regular overuse for more than 3 months of at least one acute treatment drug:
Ergotamine, triptans, opioids, or combination analgesic medications on 10 or more days per month on a regular basis for more than 3 months, or

Simple analgesics or any combination of ergotamine, triptans, analgesics, or opioids on 15 or more days per month on a regular basis for more than 3 months without overuse of any single class alone.

Another criterion is that the patient’s headaches must worsen in some way (usually frequency) as the use of acute medications becomes more frequent.

Medication overuse headache is the most common form of secondary chronic daily headache seen in headache practice, and probably accounts for about half of cases of chronic daily headache."

His article states that this is the most common form of secondary chronic daily headaches. An iatrogenic disorder is one that is caused by the medical treatment. Secondary headaches from meication overuse are definitely iatrogenid and are frequently accompanied by other iatrogenic problems such as bleeding ulcers, narcotic addictions and numerous medication side effects.

THERE ARE TIMES WHEN IT IS ABSOLUTELY NECESSARY TO CONTROL SEVERE PAIN WITH HEAVY DOSES OF MEDICATION. IT IS NOT ACCEPTABLE THAT CORRECTION OF THE UNDERLYING CONDITIONS THAT MAKE PATIENTS REQUIRE THESE DRUGS ARE NOT ADDRESSED. A PREVIOUS POST DISCUSSED IDENTIFICATION OF MYOFASCIAL TRIGGER POINTS VASTLY IMPOVING MIGRAINE TREATMENT SUCCESS.

NEUROMUSCULAR DENTISTS ARE A VALUABLE ASSET TO ALL HEADACHE PATIENTS. Many neurologists are not familiar with the science(http://www.sleepandhealth.com/neuromuscular-dentistry) behind Neuromuscular Dentistry. An excellent approach for all patients with any type of chronic migraine or tension headache to utilize a neuromuscular diagnostic orthotic for a period of about 6 -12 weeks. A neuromuscular orthotic must be worn 24 hours/day and seven days a week and therefore must be comfortable for normal daily life functions.

Most patients respond amazingly well to the diagnostic orthotic and it is rare to not see a minimum of 50% improvement in chronic daily and tension type headaches. Patients with migraines associated with ovulation and/or menstrual cycle may still have exaccerbations during those times. Patients should continue to avoid known headache triggers.

Cervicogenic headaches also respond to neuromuscular dentistry due to changes in forward head posture that gradually occur while wearing the diagnostic orthotic. As the body posture corrects it is frequently necessary to reshape and resurface the diagnostic orthotic over time. I usually start with adjustments one time a week and gradually increase the time between visits. Each patient is unique and some patients need more frequent adjustments. Other patients have "miracle relief" with complete elimination of all migraine and muscle pain after the first visit. Often the "miracle relief" patient is not cured but just has so much relief and never felt so good that they report complete relief. When they get used to this new feeling (not having pain is often a totally new sensation) there are often still residual problems to address.

Patients discuss feeling a lightness or sense of energy because they are no longer utilizing so many physiologic and psychologic processes to cover up the pain and cope.

I often find that a few visits into treatment I "meet the paient for the first time" because they have changed in dramatic ways that are far more complex than presence of absence of pain. There is a "lightness to their soul" or a new hope not of pain relief but of resuming their life. One patient described her orthotic as ending "Life Interruptess" and I have had spouses tell me that they have rediscovered the person who was lost in a sea of pai.

This does not always translate into total cures, frequently a patient in constant pain for years findsa large bulk of pain gone and they can then begin the process of solving remaining problems that are now discrete entities. Prior, when drowning in pain they could not see the forest for the trees. As overall pain relief occurs they can now actually have proper diagnosis of other problems.

Depression and pschological disorders frequently disappear. I describe as the difference between psychosomatic pain and Somatophsycic pai.

In simplest terms psychosomtic pain translates into "I HURT BECAUSE I'M CRAZY" while Somatopsychic pain translates into "MY PAIN IS MAKING ME CRAZY". Relieve the pain and the "CRAZY" is gone. It is normal to be depressed when you are in constant pain, in fact, "IF YOU ARE IN CONSTANT TERRIBLE PAIN AND DO NOT BECOME DEPRESSED YOU ARE CERTIFIABLE" Depression is a normal outcome of chronic pain.

There is no true cure for long term pain because the pain has changed your past, who you were and what you did. Relief of pain lets you move forward without the weight of a 1000 pound albatross around your neck but the only true cure would be " A DO-OVER ON THE YEARS WHERE CHRONIC PAIN RULED YOUR LIFE" and unfortunately no one can roll back the clock and make you the person you would have been without your pain.

Dr Tepper discusses the many names given to these medication overuse headaches in his article: "Many terms have been used to describe medication overuse headache in the past, such as analgesic-rebound headache (or just rebound headache), transformed migraine with medication overuse, and even chronic migraine. The lack of uniformity in terminology makes for confusion in the literature and difficulty in communicating with patients and colleagues. Some authors mean medication overuse headache when they say chronic daily headache." He spells out why so many patients cannot find answers to their problems. Clearly identifying both the cause and the symptoms is vital in treatment. A essential element in identifying the cause is ruling out other causes. This is why a neuromuscular dental orthotic is so vital not just for treatment but as an essential element of the diagnostic protocol.

Dr Tepper goes on to state: "Complicating this diagnostic confusion is a debate as to whether chronic daily headache in general should be treated as a primary or secondary headache disorder." THIS IS EXTREMELY IMPORTANT! IF WE ARE NOT CLEAR IF WE ARE TREATING THE UNDERLYING CONDITION OR THE IATROGENIC SYMPTOMS OR MEDICATION OVERUSE, MORE HARM CAN BE DONE TO THE PATIENT. ACCORDING TO DR TEPPER " Some European headache specialists insist on a strict division between primary and secondary daily headaches, and medication overuse headache is one of the latter. Many American specialists believe that chronic daily headache is a collective description or phenotype rather than a diagnostic category, and that it is usually associated with and exacerbated by medication overuse. The International Classification of Headache Disorders uses the term “chronic migraine” for primary daily headache, and “medication overuse headache” for secondary daily headache or rebound." THIS LACK OF CLARITY IN DIAGNOSIS IS A MAJOR FAULT IN TREATMENT OF CHRONIC DAILY HEADACHE.

It is important to remember that the meication is used primarily to alter changes caused by the trigeminovascular system. The easies and safest method of altering the Trigeminal nervous system is thru altering afferent impulses that create noxious results. The NTI-TSS appliance is considered an extremely effective, if not most effective migraine treatment. Unfortunately is may complicate achieving a long-term health position. I frequently will use the NTI or a version of it in nocturnal (night-time) appliances but find that for patients looking for long -term complete relief have better results with neuromuscular orthotics. It is postulated that part of the effect of the NTI is on sleep apnea by increasing tongue space and reducing apnea. It is well known that when patients have apneic eventsthat result in changes in sleep stage clenching frequently results. When patients with sleep apnea are treated via Dental Sleep Medicine (http://www.ihatecpap.com) complete or partial headache and migraine relief is frequently reported.

Central Sensitization is a major factor in acute problems becoming chronic and in the development of RSD or CRPS. According to Dr Tepper "Complicating the dilemma, acute migraine-specific medications such as triptans and dihydroergotamine (Migranal) work better when taken early in migraine attacks, before central sensitization and allodynia develop with attendant photophonophobia and sensitivity to other stimuli. On the other hand, overuse will lead to medication overuse headache."

The use of Neuromuscular Dentistry can help prevent central sensitization and even reduce the changes caused by neural plasticity. Central sensitization or changes to the CNS may be reversible if noxious input to the system is reduced. This is the same whether using NTI-TSS or Neuromuscular Orthotics. The difference is NTI uses a new pathological input to turn off or overide a more powerful noxious input whereas a neuromuscular orthotic is used to reduce all noxious input and to return to a normal physiologic state. When sleep apnea is present it is advisable to treat daytime and nightime conditions with distinct appliances.

The next section of Dr Tepper's article I have some points of Disagreement and I will use all capitals for my comments.

"SYMPTOMS VARY (from article)

The symptoms of medication overuse headache vary in frequency, severity, location, quality, and associated features, both among patients and in the same patient. This is because the disease itself varies and also because of differences in the type and frequency of medication intake. Still, some features help to define this problem, and failing to recognize them may account for a widely held clinical feeling that these patients are “difficult.” THIS WIDE VARIETY OF PROBLEMS WILL FAIL TO SEPERATE PRIMARY FROM SECONDARY HEADACHES.

History of episodic migraine. Generally, medication overuse headache does not occur in nonmigraineurs. THE ACTUAL DIAGNOSIS OF MIGRAINE IS FREQUENTLY SUSPECT AND CHRONIC USE OF DRUGS LIKE EXCEDRIN FREQUENTLY OCCURS IN PATIENTS WITH TMD, CERVICAL PAIN AND MUSCULAR TENSION-TYPE HEADACHES.

Headache on most days of the month. Whenever a migraineur starts having headaches on more days than not, the diagnosis of medication overuse should be considered. REMEMBER THERE CAN BE MIGRAINES MIXED WITH TENSION TYPE HEADACHES AND FREQUENTLY THEY BLEND TOGETHER IN THE PATIENTS MIND AS MORE SEVERE AND LESS SEVER MIGRAINE WHEN IN REALITY THEY HAVE TENSION-TYPE HEADACHES OR TMD HEADCHES WITH PERIODIC MIGRAINE.

Overuse of acute medications. The criteria (see above) allow for combining days of acute medication use. For example, if a patient takes a combination analgesic on 5 days and a triptan on 5 different days, that would still be enough days of acute treatment to trigger medication overuse headache.

Variable pain location (THIS IS ALSO CONSISTENT WITH TMD OR MYOFASCIAL PAIN) is a particular characteristic of medication overuse headache. Although the location may differ from day to day (front or back, rostral or caudal, unilateral or bilateral), it is the quantity not the quality or location of the headaches that suggests the diagnosis.

A drug-dependent rhythm. Predictably, the headaches come on in the early morning or awaken the patient from sleep. This may be due to variable drug withdrawal. AS DISCUSSED PREVIOUSLY TMD AND SLEEP APNEA ARE THE PRIMARY CAUSES OF MORNING HEADACHES.

Neck pain. Medication overuse headache frequently involves the neck, and patients often seek and receive treatments such as muscle relaxants or injections to the neck. When patients are weaned from their acute migraine medications, neck pain generally dissipates. The neck pain, however, can recur episodically with their remaining, now-episodic acute migraines. Neck pain associated with medication overuse headache is not usually a sign of a primary neck disorder; rather, it is a symptom of medication overuse headache itself. NEUROLOGISTS FREQUENTLY DO NOT CONSIDER MANUAL OR ANATOMICAL CAUSES OF NECK PAIN IN RELATION TO HEADACHES. PATIENTS WHO ARE OVERCLOSED TEND TO HAVE FORWARD HEAD POSITION THAT CAUSES NECK PAIN AND CERVICOGENIC HEADACHES. THE QUADRANT THEOREM OF GUZAY EXPLAINS WHY THIS HAPPENS. ROCOBADO HAS SHOWN THAT EVERY CM OF FORWARD HEAD POSTURE REQUIRES TWICE THE EFFORT TO MAINTAIN POSTURE. A TWO INCH FORWARD HEAD POSTURE WOULD RESULT IN 3200% INCREASE IN TONIC MUSCLE ACTIVITY TO LOW BACK.

Concomitant depression and anxiety are comorbid with episodic migraine, but appear to be more common with medication overuse headache. Treating the depression or anxiety does not restore an episodic pattern of migraine; weaning from the overused medications remains the most important intervention. A frequent clinical error is to diagnose and treat the psychiatric issues without recognizing medication overuse as the primary problem. A FREQUENT PROBLEM IS WHEN ONE ASSUMES THE DEPRESSION IS THE CAUSE OF PAIN INSTEAD A SECONDARY RESULT OF PAIN. SLEEP DISTURBANCES ASSOCIATED WITH DEPRESSION CAN CERTAINLY INCREASE BOTH MUSCLE PAIN AND HEADACHES. DEPRESION IS FREQUENTLY SEEN WITH UNDIAGNOSED SLEEP APNEA.

Nonrestorative sleep is almost always reported by patients with medication overuse headache. This is often due to the caffeine contained in combination analgesics or to excessive dietary caffeine intake, but it may also be part of the daily acute drug withdrawal syndrome. The sleep problems are also associated with the concomitant depression. Sleep often improves after weaning from the offending substance or substances. As with neck pain, patients do not have a primary sleep disorder—the sleep disturbance is a symptom of medication overuse headache. MANY OF THESE PATIENTS, ESPECIALLY WOMEN DO HAVE AN UNDERLYING SLEEP DISORDER, UARS OR UPPER AIRWAY RESISTAANCE SYNDROME BUT IT DOES NOT MEET THE DIAGNOSTIC CRITERIA TO BE CONSIDERD SLEEP APNEA SYNDROME. THE DEFINITIONS FOR APNEA WERE DEVELOPED ON OLD FAT MEN AND TEND TO UNDERSCORE OF MISS THE DIAGNOOSIS IN FEMALES AND YOUNGER THINNER HEALTHIER PATIENTS IN GENERAL.

ALPHA-INTRUSION INTO DELTA SLEEP IS THE MARKER FOR FIBROMYALGIA BUT IS ALSO FREQUENTLY SEEN WITH TMD DUE TO AIRWAY PROBLEMS.

Vasomotor instability. Autonomic features are commonly associated with medication overuse headache. Rhinorrhea, nasal stuffiness, and lacrimation are features of medication withdrawal, especially from opioids, and are frequently attributed to sinus disease or “sinus headaches.” Many patients undergo unnecessary sinus procedures or are given antibiotics, decongestants, and other wrong medications for incorrect diagnoses. Decongestants can cause and exacerbate medication overuse headache, so they need to be withdrawn. The sinus features generally remit when the overused migraine medications are eliminated. MANY OF THESE PROBLEMS ARE RELATED TO THE NASAL CYCLE AND THE SWITCHING OF SYMPATHETIC AND PARASYMPATHETIC PROCESSES THAT OCCUR ON A REGULAR BASIS AT NIGHT. THERE IS AN EXCELLENT ARTICLE THAT DESCRIBES SOME OF THESE PROCESSES AT: http://www.cnsspectrums.com/aspx/articledetail.aspx?articleid=1163 THESE SYMPTOMS MAY BE MORE RELATED TO A NORMAL PHYSIOLOGIC PROCESS AND ACTUALLY SERVE AS A CUASE OF MEDICATION OVERUSE.

Preventive medications are less effective or ineffective until the acute medications are withdrawn. Thus, prescribing prevention without weaning is usually futile, and the patients are often dismissed as having a refractory problem. At the same time, migraine-specific acute treatments, ie, triptans and ergots, are usually also less effective. When patients complain that “nothing works,” either preventively or acutely, medication overuse headache should spring to mind. THE SAME HOLDS TRU WHEN TREATING PATIENTS WITH A NEUROMUSCULAR ORTHOTIC. EVEN THOUGH THE UNDERLYING PROBLEM MAY BE CORRECTED AND WILL PREVENT FUTURE HEADACHES THE PATIENT STILL SUFFERS WITHRAWAL SYMPTOMS THAT MAKE THEM FEEL THERAPY IS INEFFECTIVE. IN REALITY THE DRUG PROBLEM (IATROGENIC) ACTUALLY HIDES THE EFFECTIVENESS OF TREATMENT.

I TELL MY PATIENTS TO NOT CHANGE DRUG REGIMEN INITIALLY BUT TO CONTINUE ON THEIR CURRENT MEDS WHILE GOING THRU THE FIRST PHASE OF TREATMENT. ONCE STABILITY IS REACHED THEY CAN THEN GO THRU DRUG WITHDRAWAL THERAPY WHICH WILL BE EASIER BUT STILL UNPLEASANT.

Weaning from overused medications can restore the efficacy of previously ineffective treatments at the same time that a patient is restored to an episodic headache pattern. Thus, complete weaning is the pivotal clinical intervention. Clinically, there is no spontaneous remission from rebound without absolute detoxification, maintained for months. ONCE WEANED FROM MEDICATIONS THEY FREQUENTLY WILL NO LONGER NEED THESE MEDICATIONS ANY LONGER. IF THERE ARE STILL ISOLATED EVENTS THAT CONTINUE MEDICATION USE WILL PROBABLY BE GREATLY REDUCED.

THE FOLLOWING PARAGRAPH IS WHAT I FIND TRULY FIGHTENING ABOUT THIS PAPER. ASSUMING THE HEADACHE IS DUE TO MEDICATION OVERUSE IGNORES WHY OVERUSE OCCURED INITIALLY. THE LIST OF DIFFERENTIAL DIAGNOSIS ARE ALL POSSIBLE CUASES AND SHOULD BE INDIVIDUALLY AND COLLECTIVELY CONSIDERED BEFORE PATIENTS REACH TOXIC LEVELS OF MEDICATIONS THAT CAUSE IATROGENIC PROBLEMS. ALMOST ALL HEADACHES ARE RELATED TO TRIGEMINAL NERVOUS INPUT FROM THE JAWS AND TEETH AND IT ACCOUNTS FOR OVER 50% OF THE TOTAL INPUT TO THE BRAIN. SLEEP APNEA IS A SECONDARY CONDITION ALSO RELATING TO THE JAW POSITION.
"Other diagnoses entertained. The more diagnoses suggested for daily headache, and the more treatments tried unsuccessfully, the more likely the diagnosis is actually medication overuse headache. Because this condition is protean, patients and caregivers alike make more and more fanciful diagnoses such as allergies, cervicogenic headache, temperomandibular disorder, occipital neuralgia, chronic Lyme disease, and systemic candidiasis. A useful strategy is to assume that daily headache is likely due to medication overuse. And since medication overuse headache is generally treatable, patients labeled as having refractory headaches often are dramatically improved by appropriate intervention."

MEDICATION OVERUSE IS REAL AND A SERIOUS PROBLEM BUT TO DISCOUNT WHAT ARE POSSIBLY KEY ELEMENTS IN TREATMENT IS NOT ONLY FLWED BUT DANGEROUS BECAUSE FREQUENTLY PATIENTS WILL IN DESPERATION SEEK OUT NON-PROFESSIONALLY PRESCRIBED DRUG ALERNATIVES. NEUROMUSCULAR DENTISTRY, NUCCA, A?O CHIROPRACTIC, PHYSICAL THERAPY, MASSAGE THERAPY, TRIGGER PONT INJECTIONS AND NUMEROUS OTHER PHYSICAL MEDICINE MODALITIES SHOULD BE USED TO DECREASE PAIN AS AN ESSENTIAL PART OF MEDICATION CONTROL.

THE USE OF NON-INVASIVE INTRANASAL SPHENOPLATINE GANGLION BLOCKS CAN MAKE THE PROCESS MUCH SMOOTHER.

THE STATEMNTS "Episodic migraine attacks appear to be generated in the upper brainstem. This region in turn activates a set of peripheral pain mechanisms, ie, meningeal inflammation and vasodilation. The peripheral pain processes turn on afferent circuits that carry the pain signals to the lower brainstem, where these signals are integrated. Finally, the central signals ascend the brainstem, stimulating autonomic nuclei that account for nausea and other vasomotor changes, proceed through the thalamus, and terminate in the cortex where pain is perceived. Thus, migraine without aura consists of three steps—a central generator, a set of peripheral pain mechanisms, and a series of steps culminating in central integration. (Aura involves other steps, not outlined here.)" DESCRIBES WHAT HAPPENS TO PATIENTS BUT PLEASE NOTE THE TRIGEMINAL NERVE CONTROLS BLOOD FLOW TO THE ANTERIOR 2/3 OF THE MENINGES OF THE BRAIN. A NEUROMUSCULAR ORTHOTIC CAN HELP ADDRESS THAT INFLAMATORY/VASCULAR DILATION PROCESS. THE AFFERENTS THAT CARRY PAIN ARE PRIMARILY RELATED TO THE TRIGEMINAL NERVOUS SYSTEM WHICH IS DIRECTLY ADDRESSED BY A NEUROMUSCULAR ORTHOTIC. THE AUTONOMIC CONDITIONS ARE DISCUSSED IN THE PREVIOUSLY REFERENCED ARTICLE

I WOULD REDEFINE MIGRAINE WITHOUT AURA AS A PERIPHERAL TRIGGERS (USUALLY TRIGEMINAL NERVE BUT CAN BE OLFACTORY OR VISUAL)WHICKH THEN SETS OFF CENTRAL MECHANISM WHICH INCREASES PERIPHERAL PAIN MECHANISMS.

THE TRIGEMINAL NERVE IS THE MAJR SWITCH THAT STARTS THE PROCESS. THERE MAY ACTUALLY BE MANY PERIPHERAL SWITCHES IN ADDITION TO THE TRIGEMINAL NERVE AND WHEN THE RIGHT COMBINATION AND INTENSITY OF INPUT REACHES THRESHOLD THAN THE CENTRAL PROCESS BEGINS.

NEUROMUSCULAR DENTISTRY DEALS WITH PREVENTING INITIATING THRESHOLD FROM BEING REACHED.

Labels: headache neuromuscular dentistry, MEDICATION OVERUSE HEADACHES, migraine neuromuscular dentistry, neuromuscular dentistry

I am currently working very diligently to make the I Hate Headaches site the most comprehensive source for Neuromuscular Dentistry and to help the public "find a Neuromuscular Dentist" While there are a few doctors who are early members of our site I will help patients find neuromuscular dentists in their area.

I frequently find that patients wish to come to my office to see me personally. My office can make arrangements for out of town patients who want to experience the changes neuromuscular dentistry can accomplish. I currently have several out of stat patients with sleep disorders, headaches, migraines and other types of TMD who travel to my office.

Please bookmark my blog and also watch for new content about neuromuscular dentistry on this site.

Labels: find a neuromuscular dentist, headache neuromuscular dentistry, information neuromuscular dentistry, migraine neuromuscular dentistry, neuromuscular dentistry

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The diagnosis of facial pain is frequently not called headache pain and often receives a wrong diagnosis. Possible causes of facial pain are TMJ disordrs, trigeinal neuralgia, parotid gland disorders, masticatory muscle pain or pain referred from the cervical an shoulder reasons. Facial pain may resolve easily with neuromuscular dental treatment but it is important to rule out pain of organic nature.

Facial pain and sinus pain are frequently different terms patients use to describe pain referred from muscles which are the easiet pain a neuromuscular dentist treats.

When there is neuralgia pain it is usually sharp, sudden and lancinating and very emotionally charge. I have had patients with trigeminal neuralgia that will protect their trigger area no matter what. It is important to identify triggers that set off this type of excruciating pain. I have seen many patients over the years with neuralgia like pains. Some resonded well to neuromuscular dental treatment immediately while others responded to trigger point injections.

Frequently the area must be calmed down by drug therapy or counter irritants like capascin cream before attempting to place a patient on a TENS unit.

Labels: facial pain, facial pain specialist, facial pain TMJ, Facial pain trigeminal neuralgia, neuromuscular dentistry, trigeminal neuralgia TMJ, trigeminl neuralgia

A recent article in the Journal Pain looked at incidence of facial pain in the Netherlands. The authors wanted to " The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH)"

Trigeminal Neuralgia and Cluster Headaches were the most common types and both increased with age. This study found that facial pain was rare but more common than expected prior to the study. The trigeminal nerve is frequently a culprit in many types of pain disorders. Many, but not all patients with trigeminal neuralgia diagnosis will respond positively to neuromuscular treatment.

My take on this is a little different because I frequently see patients who complain of sinus pain, tooth pain eye pain while pointing to painful areas. Thsi study would have ignored thos findings. Over the years I frequently see patients that have been given a diagnosis of a disorder neuromuscular dentistry can't treat yet they get better with an orthotic. This does not mean the orthotic can treat those conditions and often just points out a misdiagnosis. I have had patients diagnosed with MS whose symptoms disappeared with my treatment. That does not mean I treated the MS, it may just mean that the diagnosis was incorrect.

There is no harm in a second or third opinion.

Pain. 2009 Dec 15;147(1-3):122-7. Epub 2009 Sep 26.
Incidence of facial pain in the general population.
Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC.

Dept. of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands. skoop29@gmail.com
Facial pain has a considerable impact on quality of life. Accurate incidence estimates in the general population are scant. The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH) in the Netherlands. In the population-based Integrated Primary Care Information (IPCI) medical record database potential facial pain cases were identified from codes and narratives. Two medical doctors reviewed medical records, questionnaires from general practitioners and specialist letters using criteria of the International Association for the Study of Pain. A pain specialist arbitrated if necessary and a random sample of all cases was evaluated by a neurologist. The date of onset was defined as date of first specific symptoms. The IR was calculated per 100,000PY. Three hundred and sixty-two incident cases were ascertained. The overall IR [95% confidence interval] was 38.7 [34.9-42.9]. It was more common among women compared to men. Trigeminal neuralgia and cluster headache were the most common forms among the studied diseases. Paroxysmal hemicrania and glossopharyngeal neuralgia were among the rarer syndromes. The IR increased with age for all diseases except CH and ON, peaking in the 4th and 7th decade, respectively. Postherpetic neuralgia, CH and LoN were more common in men than women. From this we can conclude that facial pain is relatively rare, although more common than estimated previously based on hospital data.

PMID: 19783099 [PubMed - in process]

Labels: cluster headache treatment, cluster headaches, facial pain, glossopharyngeal neuralgia, migriane, neuromuscular dentistry, spenopalatine block TMJ, trigeminal neuralgia

Drug herapy always carries some risks. The following abstract details how a patient was treated for migraines with ergotamine. The patient was suffering from tiredness and weight loss and fever after a single dose of ergotamine. A second dose led to tongue necrosis (necrosis means death of the tissue) The authors felt that the necrosis of the tongue could have been the result of undiagnosed temporal arteritis a condition that can also cause blindness. A clinical sign of temporal arteritis is an elevated sed rate.

Ergotamine is a well known drug in migraine treatment and this is an unusual case. With neuromuscular dentistry we are always on the look out for red herrings. The patient who has a serious disorder that is causing symptoms or a serious disordersthat is not causing the symptoms but is covered up by the pain disorder.

My favorite patients to treat are patients who have had MRI's, CAT scans, Brain Scans, numerous blood tests ruling out organic diseases. These patients are "safe" because all the severe problems have been eliminated as possible causes of the problem.

Neuromuscular Dentistry cannot treat temporal arteritis which is usually treated with steroid but often dissapears after a biopsy.

PUBMED Abstract
Ugeskr Laeger. 2009 Jan 12;171(3):125-6.
[Necrosis of the tongue triggered by ergotamine in unrecognized temporal arteritis]
[Article in Danish]

Olesen JB.

Regionshospitalet Horsens, Medicinsk Afdeling. Jesper.blegvad@ki.au.dk
Tongue necrosis is a rare complication in arteritis temporalis. Our case is a 74-year-old patient who presented with weight loss, tiredness and fever during a 2-3-month period after ingestion of 2 mg ergotamine to treat her migraine. Tongue necrosis then occurred after ingestion of another 2 mg of ergotamine. Our patient had no preexisting diagnosis of arteritis temporalis. We reviewed possible clinical manifestations of temporal arteritis and cases of tongue necrosis in the world literature. It is possible that ergotamine can cause necrosis due to vasoconstriction of blood vessels which have an unstable blood flow.

PMID: 19174020 [PubMed - indexed for MEDLINE]

Labels: atypical migraine, neuromuscular dentistry, Temporal arteritis, TMJ/TMD

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

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

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

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

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

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

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

Ira L Shapira DDS, DABDSM, DAAPM, FICCMO

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

PMID: 18468270 [PubMed - indexed for MEDLINE]

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

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

The same Neuromuscular Dentistry that was used to create Pure Power Mouthguards(PPM) to help the New Orleans Saints is what is put into neuromuscular orthotics to treat chronic pain, migraines and tension type headaches. There is a continuous spectrum from total health and ideal function to poor health and function. The PPM mouthguard is trying to improve highly functional athletes with neuromuscular dentistry. Cosmetic dentistry utilizes neuromuscular dentistry to determine ideal jaw position and fuction for ideal cosmetics.

Headache treatment with neuromuscular dentistry is taking patients with pathological input that causes changes to the central nervous system and reducing the nociceptive input. As the pathology is removed the system heals. In medicine the best a doctor can hope for is to remove the impediments to healing so the body can heal itself. This is found in every field of medicine in every culture. We want to allow healing.

The brain acts as a computer noxious stimuli provoke nociceptive input. The expression Garbage in - Garbage out can apply to our brains as well as computers. The trigeminal nerve (Dentist's Nerve) is the largest contributor of input into the brain. This input comes in from jaw muscles, jaw joints, teeth and periodontal membranes. The trigeminal nerve also goes to the ling of the sinuses, tensor of the ear drum (tensor veli tympani), the tensor of the eustacian tube (tensor veli palatini) and controls blood flow to the anterior 2/3 of the brain thru the meninges.

Input into the brain is not a simple single step (like a light switch) but rather a complex menageries of thousands and thousands of switches. Different combinations of these switches can cause different effects. They can change the neurotransmitters in the brain like Serotonin or norepinephrine. These are the same neurotransmitters affected by powerful drugs used to treat pain and depression. Neuromuscular Dentistry strives to bring a healthy homeostasis into this input to allow healing. Central sensitization results when excessive long term nociceptive input wreaks havoc causing conditions like allodynia and hyperalgesia or CRPS (complex Regional Pain Syndromes or RSD, reflex sympathetic dystrophy syndrome) The body basically becomes overly sensitive to catecholamines or other neurotransmitters. This is usually the result of an I/O or input output error of the nervous system. Neuromuscular Dentistry corrects pathological input allowing healing and correction of output.

Labels: Headache treatment, migraine treatment, neuromuscular dentistry

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

My daughter has suffered several years with severe headaches many of which we have not been able to help her with. She has clicking in her jaw and winces in pain often. Her wisdom teeth were growing in wrong so we had them removed and that has not helped. Her cousin has TMJ but we live in upstate NY above Albany and there are not that many places for us to get help. If you have any suggestions we would appreciate your help.

These types of problems are very common. I would strongly suggest beginning treatment with a diagnostic neuromuscular orthotic. I would initially concentrate on headache relief. The joints will usually do much better once the muscles are healthier and the bite stable. Headaches are usally easily relieved with Neuromuscular Dentistry once the diagnostic orthotic is in place. Reversible treatment with the orthotic is an excellent beginning. If the headaches are relieved (they usually are) you can then decide how to proced.

Removing wisdom teeth will rarely help either TMJ (TMD) disorders or headaches and often makes the problem worse to to stress on the joints during extraction and muscle splinting after the extraction. I usually recommend stabilizing the bite and relieving headaches prior to wisom teeth removal.

Labels: diagnostic, headache, neuromuscular dentistry, orthotic

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

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

I HAVE REPRINTED AN ENTRY FROM THE I HATE CPAP BLOG THAT EXPLAINS WHY MANY HEADACHE PROBLEMS PERSIST AND RUN IN FAMILIES. THEIR IS A DEVELOPMENT PATHWAY THAT LEADS TO PHYSICAL AND STRUCTURAL CHANGES THAT LEAD TO HEADACHES AND MIGRAINES. WHILE NEUROMUSCULAR DENTISTRY ALLOWS US TO TREAT PATIENTS AND ALLEVIATE THE MIGRAINES AND OTHER HEADACHES IT IN IMPORTANT THAT WE RECOGNIZE THAT THESE PROBLES ARE OFTEN PREVENTABLE IF WE ACT EARLY TO PROTECT OUR CHILDREN.

FROM I HATE CPAP BLOG
DEVELOPMENTAL CHANGES IN CHILDREN WITH SLEEP APNEA MUST BE ADDRESSED AFTER REMOVAL OF TONSILS AND ADENOIDS
A recent study in the International Journal of Pediatric Otorhinolaryngology looked at arch Maxillary (upper jaw) development in children with snoring and sleep apnea and evaluated changes after adenotonsillar surgery. The physical changes did not correct after surgery and these children were left with residual problems that could plague the for their entire life. The authors concluded " Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended."

It is essential that the pediatric and dental communities recognize that children do not grow and eliminate the problems of enlarged tonsils and adenoids but rather they experience distorted growth that must be corrected. Early diagnosis and treatment of airway is essential for proper dento-facial growth. The NHLBI considers sleep apnea to be a TMJ Disorder. Sleep Apnea, Snoring, Migraines, Tension Headaches, Chronic Daily Headaches and TMJ disorders all begin in a common developmental pathway.

Dental Sleep Meicine and Neuromuscular Dentistry are key in improving the quality of live of these patients as adults. Early intervention may greatly reduce the number of patients who develop these problems.

nt J Pediatr Otorhinolaryngol. 2009 Nov 23. [Epub ahead of print]
Development of craniofacial and dental arch morphology in relation to sleep disordered breathing from 4 to 12 years. Effects of adenotonsillar surgery.
Löfstrand-Tideström B, Hultcrantz E.

Department of Surgical Sciences, Division of Otorhinolaryngology, University of Uppsala, SE - 751 85 Uppsala, Sweden.
OBJECTIVES: To study the development of craniofacial and dental arch morphology in children with sleep disordered breathing in relation to adenotonsillar surgery. SUBJECTS AND METHODS: From a community-based cohort of 644 children, 393 answered questionnaires at age 4, 6 and 12 years. Out of this group, 25 children who were snoring regularly at age 4 could be followed up to age 12 together with 24 controls not snoring at age 4, 6 and 12 years. Study casts were obtained from cases and controls and lateral cephalograms from the cases. Analysis regarding facial features and dento-alveolar development was performed. RESULTS: Children snoring regularly at age 4 showed reduced transversal width of the maxilla and more frequently had anterior open bite and lateral cross-bite than the controls. These conditions persisted for most cases at age 6, by which time 18/25 had been operated for snoring. In most of the cases, surgery cured the snoring temporarily, but their width of the maxilla was still smaller by age 12-even when nasal breathing was attained. At age 12, the frequency of lateral cross-bite was much reduced and anterior open bite was resolved, both in cases and controls. The children who snored regularly at age 12 operated or not operated, showed a long face anatomy and were oral breathers (this applied even to those who were operated). The seven cases who were not operated and the five who were still snoring in spite of surgery at age 12, did not have reduced maxillary width as compared to the controls. CONCLUSION: Dento-facial development in snoring children is not changed by adenotonsillar surgery regardless of symptom relief. If snoring persists or relapses orthodontic maxillar widening and/or functional training should be considered. Collaboration between otorhinolaryngologist, orthodontists and speech and language pathologists is strongly recommended.

PMID: 19939470 [PubMed - as supplied by publisher]

Labels: cluster headaches, development, neuromuscular dentistry, TMJ

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

I recently treated a patient who a a continuous headache for over 50 years. I originally saw hew husband and my Schaumburg Chicagoland Dental Sleep Medicine Associates office to treat his sleep apnea with an oral appliance. We successfully treated his sleep apnea and in the process eliminated his snoring which she commented greatly improved her life. We then discussed her headaches and did spray and stretch with ethyl chloride and relieved her 50 year headache and gave her an Aqualizer appliance as a temporary "crutch" Her headache stayed away until the Aqualizer broke.

I nest saw "M" at my Gurnee office and did a diagnostic appointment and a diagnostic orthotic. Her next visit she reported being totally headache free. LIFE CHANGING! Over the last few months we have reconstructed her mouth to the position determined by the diagnostic orthotic and she remains headache free despite extremely high family stress due to medical issues.

Her grandchildren would ask her everyday "Do you still not have a headache."

Labels: atypical migraine, cluster headaches, Gurnee, neuromuscular dentistry, Schaumburg

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