Treatment of Muscle Spasm, Muscle Pain and Myofascial Pain in TMJ Disorders: Myomonitor and ULF TENS

Dr. Shapira Blog, TMJ 0 Comments

This is an answer I gave on Reddit.com to the question of treating muscle spasm in TMD disorders associated with a close-lock TMJ. A link to discussion will be at bottom of post

“What would you recommend doing about the muscle spasms?” is an excellent question. The first step is to make a specific diagnosis. You question is perfectly meaningless without understanding the type of muscle spasm we are talking about.

Acute Muscle Spasm is usually related to specific trauma and treatment is symptom specific. This does need to be differentially diagnosed from myoclonic muscle problems (both positive and negative) which could be related to underlying disorder.

Acute muscle spasm and muscle splinting can be closely related when an acute injury leads to muscle splinting or contacture of muscles to protect an area of injury. This can be a muscle tear, broken bone, damaged joint or tendon or tendon attachment problem. A blood clot can also result in acute muscle spasm but is rear in TMD.

Acute muscle spasm will usually self correct and is probably what happened to you in the episode you descibed as a close-lock though it is possible you had acute spasm and a partial dislocation of the disk.

Muscle splinting is an important body function that protects against additional injury and allows some function.

If the injury is a muscle tear or if the spasm is strong enough to cause a tear in the muscle you have a completely different problem. You will still have splinting and severe muscle inflamation and ice will usually be first line of approach. It is also possible to tear a tendon or have enthesis of tendon attachment. These all appear very similar to acute muscle spasm but are very different.

Muscle Splinting can lead to Myofascial Pain and Dysfunction (MPD) with trigger points, taut bands and referred pain. This is the most common type of pain anywhere in the body and is often misdiagnosed to the fact that the pain and where it is coming from are usually not correctly identified when doctors are not familiar with these problems. In the TMD field this often leads to Root Canal Treatment, Extractions and diagnosis of non-existent sinus or ear infections

MPD diagnosis is crucial. When confronted with this type of “muscle spasm” Travell Spray and Stretch techniques can often give instantaneous relief. Hot and Cold and Stretching can all be useful. Teaching patients to use Spray and

Stretch with vapocoolants at home is ideal and should be taught to patient. MPD is caused by repetive strain injuries and correction of these problems is important. This may be related to postural condition, anxiety and stress and muscle misuse. Not correcting underlying structural issues is unwise for many patients, it is ethically required to explain postural considerations including bite to patients.

Treatment with ULF-TENS is an excellent modality. The Myomonitor has been used to relax muscles in Neuromuscular Dentistry for over 50 years. It works as a muscle stim peripherally causing muscles to contract and relax every 1.5 seconds. This time is based on time it takes nerve and muscle membranes to return to normal after firing. This effectively eliminates fatigue and and causes repetitive contraction and relaxation of muscles increasing blood flow with nutrients from blood and taking away waste products.

NMD usues this on muscles innervated by the Trigeminal Nerve and the Facial Nerve (cranial nerves 5 and 7 respectively). In TMD patients this relaxes all muscles that are trigeminally innervated. This includes the masseters, the medial pterygoids, the temporalis, the superior and inferion lateral pterygoids, the sphenomandibularis, the Tensor Veli Palatini that opens and closes eustacian tubes and the Tensor Veli Tympani that cotrols tension and eardrum and the anterior belly of the digastric. It also works on muscles innervated by facial nerves when used in standard position over coronoid notch.

The myomonitor can also be used on muscles anywhere in the body directly or indirectly such as on accessory nerve (cranial nerve XI) to work on upper neck, back and shoulder muscles. The BioTens is another ULF-TENS that is used by some NMD dentists. There are many reasons why the Myomonitor is special in dealing with bites and high tech adjustments but the BioTens is excellent at relaxing muscles and I often use it on Cranial nerve XI.

Nutrition is important in dealing with muscle issues and muscles require both calcium and magnesium to contract and to relax. Some medications can cause severe muscle pain and issues.

Trigger point injections, dry needling, prolotherapy, prolozone therapy are all used to treat muscle spasm and taut bands. Spray and Stretch should be utilized with injections .

Posture stability is key. This video https://www.youtube.com/watch?v=kdWhfeOcFAQ is a patient with TMD/ Headache/Migraine that is secondary to postural instability of hips. Treatment will fail if initial problem is ignored. This patient had a similar experience years previously.

We swallow 2000 times a day when our teeth touch momentarily when there is underlying postural instability we are more likely to have repetitive strain injuries. Clenching, grinding and misuse of muscles exacerbates these problems. Preventing issues is more effective than treating them after the fact. It is far easier to change the oil than change the engine in your car. It s better to prevent severe damage to TM Joints that wait till there is a disaster.

Locked Jaw – Is this permanent damage to my jaw? from TMJ

Dr Shapira is Awarded Diplomate Status By American Board of Sleep and Breathing and is Diplomate of American Board of Dental Sleep Medicine.

Dr. Shapira Uncategorized 0 Comments

Treatment of Sleep Apnea with oral appliances is an excellent alternative to CPAP for mild to moderate sleep apnea and an alternative for severe sleep apnea when patient do no tolerate or want CPAP.

Since 1982 Dr Shapira has been a leader in the field of Dental Sleep Medicine.  He sees patients in Highland Park and Gurnee Il.

HIGHLAND PARK, ILLINOIS  3500 Western Ave, Suite 101 60035     847-533-8313      www.ThinkBetterLife.com

GURNEE, ILLINOIS   310 S Greenleaf   60031       847-623-5530     www.DelanyDentalCare.com

Dr Shapira has added Diplomate Status by the American Board of Sleep and Breathing to his long history of being in the forefront of Dental Sleep Medicine.  He first became involved in Dental Sleep Medicine and the treatment of Sleep Disorders in 1982.  In 1985 Dr Shapira began research evaluating jaw position  as a visiting Assistant Professor at Rush Medical School in Chicago.

The Sleep Disorder Dental Society (SDDS) was the first organization dedicated to the science and practice of Dental Sleep Medicine and attended the first meeting in 1992 in Phoenix.  Dr Shapira was one of only 20 dentists at that meeting and the only dentist serving as an Assistant Professor of a medical School.  He was later credentialed by the SDDS.  The Sleep Disorder Dental Society became the American Academy of Dental Sleep Medicine and the American Board of Dental Sleep Medicine was formed and Dr Shapira was awarded Diplomate status.

He was also a founding member of DOSA or the Dental Organization of Sleep Apnea dentists.  He taught courses to hundreds of physicians and dentists and lectured on the subject as the American Academy of Anti-Aging Medicine.  One lecture from 1998 became a chapter in a medical textbook on Anti-Aging Medicine.

Dr Shapira was honored but being chosen to write the Guest Editorial when CRANIO: or the Journal of Cranio Mandibular Practice changed its name to the Journal of Craniomandibular and SLEEP Practice due to his influence in the growth of this  important medical  field that brings together the practice of Slkeep Medicine, Cardiology, Pulmonary Medicine and Dentistry

Dr Shapira is now a leader in the field of Epigenetic Orthodontics/ orthopedics and the use of the mRNA version of the DNA Appliance to offer possible permanent cures of Sleep Apnea through growth of the airway in a process called pneumopedics.

Dr Shapira practices in Gurnee at Delany Dental Care   847-623-5530

and in Highland Park  847-533-8313

 …

Chicago: Learn How to Self-Administer Sphenopalatine Ganglion Blocks

Dr. Shapira Blog, Chicago, Uncategorized 6 Comments

In 1986 I learned about Sphenopalatine Ganglion Blocks from a patient who brought me the book, “Miracles on Park Avenue” and wanted me to find him a doctor who did the procedure in Chicago. I was amazed when I read the book and was dismayed when I could not find anyone in the Chicago area who did the procedure.

I learned the procedure from Dr Jack Haden in Kansas city that same year and I have used it ever since. Initially I did a lot of intra-oral injections through the greater palatine foramen because it was a “comfortable” injection for me to give in an area I routinely gave anesthetic. Later, I learned techniques for extra-oral injections which were initially outside my comfort zone. I have embraced them over the years for their ease and predictability.  My Blog at www.SphenoPalatineGanglionBlocks.com has a wide range of information about Sphenopalatine Ganglion Block including indications and history of this “Miracle Block”.

I also took a while to be comfortable with doing the trans-nasal block because it was outside my aera of comfort. I have done thousands of these over the years and have adapted my techniques. In the beginning I always brought the patients in to my office for me to do the SPG blocks.

I have always had long-distance patients who traveled to see me for TMJ treatment and neuromuscular treatment and UI would teach my patients how to treat and eliminate their pain between visits with Travell Spray and Stretch techniques. This was life-changing for my patients who could now turn off severe head, neck and facial pain as well as migraine without a trip to my office. This was initially difficult because pharmacies did not understand the prescriptions and vapocoolant spray was often hard for patients to buy.

Over time, it became routine for me to automatically offer this to all patients. I would also teach them the basic principles so they could relieve pain anywhere in their body.

Empowering patients to take control of their pain without prescription medications resulted in better patient care, fewer visits both to my office and to other physicians and emergency rooms in hospitals.

I later began utilizing home ULF-TENS (Myomonitor) units to my patients for home use rather than just in my office and againfound a tremendous improvement in my ability to care for my patients and in their quality of life.  The Myomonitor also acts as an at home on demand Neuromodulation device for the Sphenopalatine Ganglion.  The Myomonito has over a 50 year safety record.

Every time I empowered patients to self-care I was rewarded with great patient appreciation for my efforts. The same level of pain relief with fewer doctor visits improved the quality of thei lives. Truth is, “Quality of Life Sucks when you are in a Doctor’s office or waiting in an ER.

Success rates for treatment improved with fewer visits and lower costs.  This link is to videos of patients who have experienced SPG Blocks.  https://www.youtube.com/playlist?list=PL5ERlVdJLdtlk8PbufsI0l_MzHo4oOb6g

I used the Sphenopalatine Ganglion Block initially only as a measure of last resort, when other treatments were not working well. My patients who received SPG Blocks taught me that they did better when I did the blocks and the number of visits decreased while their quality of life increased. I remember when I first began to teach patients how to self-administer it was with great trepidation and I did blocks twice a day in the office for two days before teaching them to self-administer because I was worried about adverse reaction, even though they never occurred. Twice a day administration drastically improved the positive effects of the blocks as the blocks appeared to have a cumulative action and increased exposure in frequency and duration increased effectiveness.

I no longer reserved these for patients with TMJ and Facial pain but began to use them for Anxiety, depression and for problems like dental phobias and that were either difficult to treat or resistant to treatment. Gradually, I began to teach self administration to all my patients and found they appreciated having control.

Recently several devices have received FDA approval for delivering anesthetic to the area of mucosa overlying the Sphenopalatine Ganglion and physicians began to bring patients in for a series of 10 treatments (every two weeks) for $750.00 per treatment or $7500 for a course of treatment. (Blue Cross / Blue Shield recently stopped paying for these blocks calling them experimental but in reality I think they became too expensive) These devices are the Sphenocath, the Allevio and the TX 360. All devices are expensive and a single use device costs a physician about $75.00.

When I teach patients to self-administer SPG Blocks I no longer use the cotton-tipped applicators but have switched to cotton-tipped catheters that supply continual capillary feed to the mucosa over the Sphenopalatine Ganglion. This has, in my opinion increased the effectiveness far beyond any of the commercial catheters.

The Sphenocath, the Allevio and the TX 360 are all basically “squirt guns” that shoot a small amount of anesthetic over the mucosa covering the Sphenopalatine Ganglion. Ideally patients will remain supine for 10-20 minutes to increase absorption time.

The cotton-tipped catheter in contrast delivers a continual flow of anesthetic to the mucosa and can be kept in place for 20 minutes to several hours and can be refilled as needed. Due to the continual flow there is no reason to stay supine (on back) but with acute severe pain an initial supine position may increse speed of onset. The size of the cotton-tipped nasal catheter is larger than the other devices and there is certainly cases where I use a Sphenocath or TX360 in my practice. If I teach self-administration I have my patients use the Sphenocath because it is reusable at home. The TX360 can esily be utilized for self administration but is a single use device only.

The cost to the patient of doing a bilateral SPG block with cotton-tipped nasal catheters after initial appointments is less than $1.00. This is an enormous cost saving to the patient and to insurance companies and makes it far less expensive than almost any of the prescription medications available for treating migraine and chronic daily headaches.

In addition there are virtually no side effects from medication. I generally use 2% lidocaine that is extremely safe and has anti-inflammatory properties.

The biggest savings is in time and medical expenses as patient no longer have to leave work for medical visits or suffer long ER waits and thousands of dollars of expense. The biggest savings is TIME. It is the one thing that if we spend it we can never get it back.

I usually will start the self-administration protocol as twice daily for multiple reasons. The two main reasons is it offers better immediate control of even severe pain and secondly if a patient is doing it twice daily they rapidly develop a high level of expertise and can do it without problems in the future. In patients with tight nasal passages they tend to become easier to navigate over time with repeated applications.

I have taught patients from across the United States as well as International patients how to Self-Administer Sphenopalatine Ganglion Blocks.

This link is to over 100 videos of patients treated with Neuromuscular Dentistry, Trigger Point Injections, Sleep Apnea Appliances and SPG Blocks: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

I used to use SPG Blocks only for patients with the most difficult problems, I was wrong.  I now believe it should be part of the diagnostic work-up for all headache patients before they receive medications and injections like BOTOX.

Chicago Metropolitan area has three airports: O’hare Airport, Midway Airport and Mitchell Field just south of Milwaukee.  O’hare and Mitchell are the most convenient to my office.  The office is also located on the North Line of Metra (Union Pacific to Kenosha) at the Fors Sheridan Train Station.

Preventing Pediatric Sleep Apnea and the Often Disturbing Consequences

Dr. Shapira Blog 0 Comments

pediatric_sleep_apneaCHILDHOOD SLEEP APNEA: Preventable and treatable but time is of the essence. Early treatment is always preferred.

 

THE DANGEROUS EPIDEMIC THAT PARENTS CAN PREVENT!

 

I lecture on the” Common developmental pathways of TMJ, Sleep Apnea, ADD, ADHD, Migraines, Mouth breathing, myofascial pain and poor posture”

 

BEWARE OF THESE SIGNS AND SYMPTOMS IN YOUR CHILDREN AND GRANDCHILDREN, I CAN AFFECT THEIR FUTURE LIVES!

Signs your child may have sleep disordered breathing? Daytime symptoms and nighttime symptoms of childhood. Looking for these symptoms and treating as early as possible can drastically improve your child’s life.

Sleep disordered breathing is very serious disorder that can affects every aspect the of physical development of your child. This includes actual brain and nervous system development and the neural pathways that will persist throughout your child life.

All snoring or signs of Sleep Apnea should be taken very seriously. In children even one apneic event is too many. If you have reason to suspect your child has sleep apnea please talk to your pediatrician or dentist.

Dentist who treat sleep apnea, are involved in Orthodontics, and especially orthopedic growth appliance, myofunctional therapy and TMJ disorders are often the specialists of children’s breathing.

WARNING SIGNS: IT IS VITAL FOR PARENTS TO BE AWARE OF THESE SIGNS AND SYMPTOMS.

Mouth breathing. Difficulty with nasal breathing, or through their nose may be due to deviated septums, tethered tongues or tongue tie, enlarged tubinates,: allergies.

When children constantly breath through their mouth it can also change their facial development.

ADD or ADHD

Changes in brain development from disturbed sleep, low oxygen saturation and other sleep issues is now suspected o be the underlying cause of up to 95% of ADD, ADHD, oppositional behavior and other behavioral disorders.

Hyperactivity:

I initially became involved in treatment of sleep apnea in the 1980’s due to my son Billy. After repeated visits to ENTs and pediatricians with concerns about night-time breathing I took matters into my own hands after we were told the Billy had ADD, ADHD, and needed to put off starting kindergarten and put him on Ritalin for life.

Billy was always a poor sleep with multiple awakenings and very hyperactive during the day, like a tightly wound spring.

I took hi to Rush Medical School and had a sleep study, he had an apnea index of 60. We took out tonsils and adenois and widened his mouth orthodonticlly and released tongue and lower lip ties. He went ro 50% growth curve to 90% growth curve, became an “A” student and graduated college Double Major, Double Minor magna Cum Laude.

DRUG OF CHOICE OXYGEN not RITALIN! couples with good sleep.

Behavior problems. Por sleep leaves these children with a difficult time just making it through the day and often is seen as behavioral issues.
Failure to thrive. Failure to thrive means having difficulty learning and doing well school, making friends, and being overall successful.

Stinted growth. As I explained with my son there was a dramatic change in growth. Growth hormone, sex hormones and cortisol are controlled during sleep as is insulin resistance. Children with childhood sleep apnea growth get stinted, Adults also are affected by these changes leading to increased belly fat and decreased muscle mass in sleep apneic adults. If you have sleep disorder that constantly disrupts your sleep your not going to grow and repair your body as fast.

Frequent memory problems especially short term memory problems. There is a connection to Alzheimers and Dementia but not a cause and effect. Poor sleep will bring these conditions on more severely and more quickly in patients genetically inclined to experience them.

  • Wakes up frequently with dry mouth and/or headaches or feeling disoriented. Grogginess in the AM or frequent pushes to snooze alarms
  • Frequent allergies or upper respiratory infections, nasal mucous build up, phlegm build up, sinus pressure and vacuum sinusitis
  • Large tonsils and adenoids
  • High blood pressure
  • Depression and anxiety
  • Feels tired or being hyperactive (opposite sides of same coin) all of the time. Difficulty in paying attention is school or concentrating
  • Excessive irritability, frustration and feelings of worthlessness.
  • Constant puffy eyelids with dark circles undr the eyes. The dark circles are blood that is not oxygenated enough. Fluid often backs up into sinuses increasing risk of infection. Poor lymphatic drainage.

SYMPTOMS TO BE AWARE OF:

Snoring IS NEVER NORMAL IN CHIDREN!

  1. Wakes up short of breath or choking.
  2. Restless sleeping (Frequent movement around in his or her sleep, especially after loud snores).COVERS OR PILLOW VERY DISTURBED OR ON THE FLOOR. Sleeping on entire bed, often in strange or awkward poses, frequent awakenings, early morning awakenings when younger but impossible to wake as adolescent.

Childhood sleep disorder breathing or sleep apnea is estimated to affect about 4% of population but newer information suggests that might just be the tip of the iceberg.

It is estimated that over 90% of children have orthopedically deficient maxillas, a trend that started about 400 years ago due to modern living. Even our orthodontic normative values are probably pathologic.

The future of our children and the human species are at risk. These are primarily Epigenetic changes to our environment in earl childhood and not genetically determined changes. They are poor phenotypic outcomes not genetic programing.

Ira L Shapira DDS, D,ABDSM, D,AAPM, FICCMO
Chair, Alliance of TMD Organizations
Diplomat, American Academy of Pain Management
Diplomat, American Board of Dental Sleep Medicine
Regent & Fellow, International College of CranioMandibular Orthopedics
Board Eligible, American Academy of CranioFacial Pain
Dental Section Editor, Sleep & Health Journal
Member, American Equilibration Society
Member, Academy of Applied Myofunctional Sciences
www.ThinkBetterLife.com
www.DelanyDentalCare.com
www.IHateCPAP.com
www.iHateHeadaches.org
www.SleepandHealth.com
www.SphenopalatineGanglionBlocks.com
https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg