Is There A Specialty of Neuromuscular Dentistry? What Exactly is Neuromuscular Dentistry? What is Dental Sleep Medicine and How are They Connected?

Dr. Shapira Chicago, Highland Park, Lake Forest, Sleep, TMJ, Uncategorized 2 Comments

There is no specialty for TMJ disorders (TMD), Neuromuscular Dentistry, Orofacial Pain,  Implant Dentistry, Epigenetic Orthopedics, Airway Dentistry, Dental Sleep Medicine and several other complex areas of dentistry.  There are many extremely well trained dentists who have taken courses and training in each of these overlapping fields of dentistry.

There is a questionable practice of trying to circumvent the American Dental Association and the State Boards across the United States to try to force state boards  thru expensive lawsuits that hurt the profession and threaten public safety  to force creation of new specialties.  An independent self-appointed board of specialties was created to award specialty status to its members.  Create a board and then use it to create a new specialty that is not defined by the dental profession but by individuals whose egos demand they have specialty titles.  Specialization is used to justify higher insurance reimbursement to the doctors and higher costs to patients.

Neuromuscular Dentistry, also called Physiologic Dentistry is based on the concept of relaxing the musculature to find “physiologic rest position” and establish an occlusion that will act to reset muscles to their healthy states.  The bite should be a reset position for the mandible.  It is extremely important to understand that the relationship of the cranium to the mandible is “NOT INDEPENDENT” of the posture and function of the entire body and brain.  Neuromuscular Dentists and their Group the International College of CranioMandibular Orthopedics are not seeking Specialty Status.  There are groups of dentists seeking a specialty of Orofacial Pain which primarily follows the medical model of diagnosis and drug treatment but these problems are rarely best treated with medication.  Neurologists are far better trained in this medical model than dentists.

What is Neuromuscular Dentistry?  I published a paper describing my definition of Neuromuscular Dentistry that was written to make it easily understandable to physicians and dentists who are not well educated in the field of Neuromuscular Dentistry.  It was originally published by the American Equilibration Society, the oldest group focused on occlusion and TMJ disorders.  It was republished with some changes in the ICCMO Anthology and is listed by Library of Congress.  It was also republished in Sleep and Heath Journal to make it readily available to the public at this link:  https://www.sleepandhealth.com/neuromuscular-dentistry-neuromuscular-dentistry-originally-published-in-the-american-equilibration-society-magazine/  (Also reprinted at end of this post)

Dental Sleep Medicine is another field that may move for specialization.  Currently the bulk of diagnosis of Sleep Apnea and other related  disorders is made by physicians and the primary treatment is CPAP.  Most studies show that mild to moderate sleep apnea treatment with oral appliances is equal to CPAP and siperior to surgery.  In spite of this most patients are prescribed CPAP even though compliance levels or actual use are very low.   When compliance and effectiveness are evaluated the treatments have equivilant medical outcomes with several studies giving an advantage to oral appliances.  Patient definitively overwhelmingly prefer oral appliances to CPAP.

Dentists treating Sleep Apnea have been frustrated by difficulty in having  physicians, particularly sleep physicians and cardiologists refer patients for oral appliances.  This is actually a problem of insufficient knowledge and more importantly their comfort levels in dealing with other physicians rather than dentists.  This is unfortunate because patients suffer.  It should be  noted that Colin Sullivan in Australia who invented CPAP utilizes an Oral Appliance.

There are several groups representing Dental Sleep Medicine.  The original group was the Sleep Disordered Dental Society (SDDS) which incorporated in 1992 and had it’s inaugural meeting.  I was one of 20 dentists worldwide who attended that meeting.  I was a visiting Assistant Professor at Rush Medical School  Sleep Service since 1985  working with Rosalind Cartwright PhD the acknowledged sleep researcher who  founded the field of Dental Sleep Medicine.  I ended up there by accident trying to find answers for my 5 year old sons’s sleep apnea.  Treatment of his sleep apnea was life changing his “ADHD” disappeared and he flourished both physically and academically with treatment.  The SDDS credentialed members for expertise in this new emerging field.

The SDDS became the American Academy of Dental Sleep Medicine in 2000 and in 2004 it formed the American Board of Dental Sleep Medicine.  I am privledged to be both credentialed by the SDDS and be a Diplomate of the ABDSM.  Read the history of the AADSM at:  https://www.aadsm.org/about.php

Dosa, the Dental Organization for Sleep Apnea was later formed as a second  organization representing Dental Sleep Medicine.  I was a Charter /Founding member of that group.  The American Sleep and Breathing Academy is a rapidly growing and politically active group working to educate not just dentists but also the medical community and government organizations of the importance of Dental Sleep Medicine in treating Sleep Apnea.  The American  Board of Sleep and Breathing also  grants Diplomate status and  I am honored to be a Diplomate in that organization.

The American Academy of Craniofacial Pain also has credentialed status in Dental Sleep Medicine.  I am a long term member of the group, originally the Academy of Head ,Neck and Facial Pain.  This group is seeking Specialty in TMJ disorders or Orofacial pain.

All of these groups are discussing seeking specialty in Dental Sleep Medicine as well.  I personally believe specialty status for dentists treating Sleep Apnea is a big mistake.  Sleep Apnea and Sleep Disordered Breathing are both closely related to TMJ disorders and Orofacial pain and trying to create numerous specialties will ultimately harm patients.  A report from the NHLBI or National Heart Lung and Blood Institute explains my feelings.  These are not independent disorders but closely tied disorders.  Please see https://www.nhlbi.nih.gov/files/docs/workshops/tmj_wksp.pdf .  This report “CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS ” explains how closely related these disorders are.

The American Academy of Integrative Pain Management is a group representing all the practitioners who practice pain management.  It is not a specialty organization but there is a medical specialty of pain management.  TMD and Orofacial Pain patients often have a need for a multidisciplinary approach and the AAIPM is known for being inclusive.    They held a full week program on Advanced Pain Management in association with Harvard Medical School in June 2018.  I am proud to be a Diplomate of this group that recently added “Integrative” to its name.  I had an amazing experience at the Harvard pain conference.  Almost universally all of the lecturers agreed that insufficient time with patients was a major problem.  Insurance plans to not reimburse for time spent during exam and consultation with patients.

The medical approach to problems is embodied by the SOAP approach.  “S”  Subjective, “O” Objective,  “A” Assessment, and “P” Plan.

First and most importance is the subjective report to the physician and the formation of rapport.  This allows the physician to order appropriate tests and form a diagnostic protocol to Assess and Plan Treatment.   The Subjective part of diagnosis is generally agreed by physicians to be most important.

The new medical care model does not value or pay for time spent in patient interviews and physicians have an average of 8 minutes per patient for face to face time.  This has led to distortions in medicine leading to excessive diagnostic testing and an increase in procedures as the center of patient care.  More importantly it has resulted in diminishing of face to face time between physicians and their families.

 

Reprint of Neuromuscular Dentistry:

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

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

This is a reprint of a previously published article. Please visit my New Website for my New Highland Park office. www.thinkBetterLife.com

The original article has two graphics that can be found at:

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 mandible’s 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
Neuromuscular Dentistry
TMJ
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.

 

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TMJ Chicago

TMJ Alphabet Soup: TMJ, TMD, TMJD,CMD, CMCD, CFP, OFP, MPD, CCPS, CRPS, TN, NMD, CR, CO, EMG, MKG, CMS, TENS, ULF-TENS, SPG, AES, ICCMO, NUCCA, A/O, AAOP, CBT, SPG

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The number of abbreviations in medicine and dentistry is amazing.  In this short post I am going to give only a small number of definitions routinely utilized in literature and culture concerning TMJ disorders, often called “the Geat Imposter”  This will be an open Blog and will be added to over time.  Please come back and visit and if you have abbreviations you think need explanation please send the to me.

The most obvious is TMJ.  It is not a disease or a disorder but an abbreviation for the TemporoMandibular Joint.  The TM Joint is made up of the Temporal Bone of the skeuu “T” and the Mandible “M” where the come together is the Joint “J”  TMJ is not a diagnosis but a body part, like saying knee or Elbow.  The Fossa of the TMJ is located in the Temporal Bone which also forms the articular eminence.  The condyle is the part of the mandible in the TM Joint.  There is also an articular Disc the divides the Joint into upper and lower compartments, the lower is where rotation takes place and the upper is where translation or sliding takes place.  Both of these movements happen simultaneously in a heathy joint as the condyle dick assembly slides forward and back, side to side or obliquely while retaining ability to rotate.  The right and left joints always work in tandem but do not mirror the actions of each other in most movements.

TMD stands for TemporoMandibular Dysfunction or TMJ Disorders and is a disorder.  It can include internal derangemets which are problems inside the joint capsule.  These can include different types of arthritis and inflammatory conditions, the can include disc displacement disorders which are often referred to as clicking.  The clicking noises often represent the sounds of the condyle going on or off the disc.  Disc displacement can occur in different dimensions and to different extents.  There are reducible and not reducible clicks which refers to the ability to recapture the disc during function.  There are also closed lock dislocations of the disc where it is displaced without reduction. A displaced disc can be extremely painful. There can also be an open lock of the TMJ which is a subluxation where the condyle hyperextends over the articular evidence.  There are disorders like joint mice that are often diagnosed incorrectly as disc disorders.  You can also have inflamation , tearing and destruction of the retrodiscal lamina that connects the disc to the posterior parts of the joint including the joint capsule.  It is also possible to hacve a capsulitis of inflammation of Joint Capsule.

TMJ DISORDERS OR TMD DO NOT ALWAYS HAVE CLICKING, POPPING OR JOINT PAIN!  The disorder can be related to joint function without having internal derangements.

TMD also includes extracapsular Disorders and this is where the fun begins.

MPD is the most common extracapsular disorder.  It stands for Myofascial Pain and Dysfunction as defined by Travell and Simmons.  It is a muscular disorder that is distinct from Muscle Spasm or Myositis.  It is a disorder of muscle dysfunction secondary to improper muscle usage.  The muscle disorder is the result of a repetitive strain injury.  Myo is for  muscle and Fascia is connective tissue.  This is NOT Myo Facial Pain referring to the face though it is frequently seen written that way.

Myofascial Pain has muscles that contain taut bands and trigger points that can cause referred pain often far from the trigger points.  There are common patterns of referred pain that are often shown in textbooks but these patterns are not for a single patient but rather a frequency diagram based on thousands of patients.  The website www.triggerpoints.net is interactive and is an excellent reference for anyone with chronic pain anywhere in the body.

NUCCA and AO or A/O  are all terms for treatment directed at the complex articulation of the head to the first and second vertebrae of the Neck.  The occiput sits on top of the first vertebrae which is the Atlas.  It is named after Atlas of Greek Mythology who held and carried the world on his shoulders.  The head sits on two shoulders of the Atlas.  The TM Joints and The Atlas Occiput joints will tend to match three dimensionally.  The Axis is the second Vertebrae and has an upward protruding part called the Dens.  The Quadrant Theorem of Guzay is a mathematical explanation of the movements of the mandible after looking at both rotation and translation and shows that the middle of these combined movements is on the Dens of the Axis.  The DENS is the centrer of rotation for mandibular movements.  NUCCA is the National Upper Cervical Chiropractic Association which is a group of Chiropractors with special traing and focus on the upper cervical spine.  A?O or Atlas Orthoganol Chiropractors utilize a specific adjustment technique for the upper cervical spine.  

This is an important area of concern for TMJ Patients because of postural connections of the jaw, jaw joints, head and upper cervical areas in creating homeostasis.  Even small changes in jaw position can affect the upper cervical spine.  Changes in head position due to upper cervical spine can crearte TMJ symptoms.

CO stands for Centric Occlusion.  It describes where the upper and lower teeth fit together with mouth closure.  MIP .is the Maximal Intercuspal Position where occlusion is totally seated even if it means a pathological slide.

CR   or Centric Relation is a more complicated issue, it is an artificial location that has at least 26 different definitions and is utilized to transfer information to an articulator be CR dentists.  CR Dentists believe that joint position of the condyle in the Fossa are key to Occlusion.  CR may be very different depending on who is determining the position.  A CR Occlusion or Centric Relation occlusal scheme will usually have a CR-CO slide because most patients cannot tolerate the CR border position and create a new centric occlusion to function.    I Do Not Utilize CR or Centric Relation position.  Long Centric is another definition of this discrepancy between CR and CO.  CO is sometimes called MIP maximum intercuspal position or a fully seated CP which may actually require some adaptive movement of the tooth in the socket which is allowed by the periodontal ligament.  This freedom disappears with implants that are immovable.

Myocentric is the neuromuscular occlusion utilized by Neuromuscular Dentists.  NMD is short for Neuromuscular Dentistry.  There are many amazing videos about NMD at https://www.reddit.com/r/NeuroMuscularDent/.   It is where the teeth meet when the muscles move the jaw from rest position to closure.  There should be minimal muscle adaptation and following closure the jaw should return to rest position and the muscles should maintain health and normal function.  Myocentric is a reset position for the mandible that allows function without inducing muscle pathology.  It is specifically designed not to induce MPD or myofascial Pain.

TENS and ULF-TENs are abbreviations for Transcutaneous Neural Stimulation and Ultra Low Frequency TENS.  Neuromuscular Dentistry utilizes ULF TENS to relax the muscles to create a healthy physiological condition in the muscles which is necessary to find neuromuscular rest and to determine neuromuscular occlusion.  Creating a healthy musculature is an important first step in neuromuscular dentistry.  EMG is Electromyography which is used to measure the electrical activity of the muscles.  MKG is a Mandibular Kinesiograph often called a CMS or computerized Mandibular Scan.  It measures in real time three dimensional movement of a magnet attached to the mandible that allows precise measurement of the magnet and infer what is happening during mandibular function.

The ULF-TENS sends current thru the coronoid notch bilaterally and causes a single synapse contraction of all of the mandibular elevator muscles as well as all other Trigeminal Nerve and Facial Nerve innervated  muscles.  The underlying basis of NMD is healthy muscles.  The condyle assumes a position within the joint based on health muscle tone.  The condyle is never forcer into an unstable orthopedic border position like CR but it can go there.

Changing the position of the head can change jaw relations and changing jaw position can change head position.  It is important to establish a very stable jaw position in neuromuscular dentistry, this is done with a diagnostic neuromuscular orthotic.

The AES is the American Equilibration Society and is the oldest TMJ organization.  I have been to their meeting for 30 years but in general the majority of members believe in CR Based occlusion.

ICCMO is the International College of CranioMandibular Orthopedics and it is primarily Neuromuscular Trained dentists  It was founded by Barney Jankelson the “Father of Neuromuscular Dentistry” as a non-commercial scientific organization.  Typically, the best neuromuscular dentists are ICCMO members.

NMD stands for either NeuroMuscular Dentistry or Dentists.  This is the philosophy of treatment where muscle health is center to all treatment.

OFP is short for OroFacial Pain or Oral Facial Pain.  This is pain centered in the head and facial regions.  Some orofacial pain doctors do not look at TMJ disorders as primarily physical medicine issues but believe they are best managed by medications.  There is a wide spectrum of doctors who treat orofacial pain but there is a group that is seeking specialty even after being denied specialty by the ADA or American Dental Association multiple times.  They are now creating a specialty outside of the ADA, a dangerous precedent.  The AAOP is the American Academy of OroFacial Pain.  This group does not believe occlusion or how teeth meet have anything to do with TMJ disorders.  They tend to utilize prescription medications and CBT or cognitive behavioral therapy a lot.  Cognitive Behavioral Therapy is valuable for many disorders.

CMD stands for CranioMandibular Dysfunction or dysfunction it the articulation which would include TMD and MPD and maybe cervical issues.  CMCD is CranioMandibular Cervical Dysfunction.

AACP is the American Academy of CranioFacial Pain and was previously the AAHNFP or the Academy of Head Neck and Facial Pain.

SPG Blocks were made famous in the best selling book “MIRACLES ON PARK AVENUE!   Celebrities and patients flocked to see Dr Mlton Reder in NYC for these blocks.  

SPG stands for Sphenopalatine Ganglion also called the Pterygomandibular Ganglion, Sluders Ganglion, Nasal Ganglion or Meckel’s Ganglion.  It is located on the maxillary branch of the Trigeminal Nerve and is associated with many of the autonomic and stress related aspects of TMJ and MPD disorders.  Many believe the TMJ disorders were first described in 1908 by Sluder as Sluder’s Neuralgia others believe this is the first description of cluster headaches.  SPG Blocks can be self-administered and are one of the most amazing treatments for a wide variety of issues.

SPG Blocks  are often used in treatment of TMJ Disorders, Migraine and Cluster headaches.

Learn more about SPG Blocks at https://www.SphenoPalatineGanglionBlocks.com

ADD and ADHD are often associated with TMJ disorders because of common developmental patterns of sleep apnea and TMJ.  Sleep disordered breathing is primary cause of both Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder.

RSD stands for Reflex Sympathetic Dystrophy more commonly called CRPS today or Complex Regional Pain Syndrome.

In Sleep issues we have AADSM or American Academy of Dental Sleep Medicine, the AASM or American Academy of Sleep Medicine, DOSA the Dental Organization for Sleep Apnea.  SA or Sleep Apnea, AHI= Apnea-Hypopnea Index, AI= Apnea Index, RDI = Respiratory distress index, RERE is Respiratory Related Arousal , UARS is Upper Airway Resistance Syndrome which is related to Fibromyalgia via the Alpha Intrusion into Delta Sleep.  REM is short for Rapid Eye Movement seen during dream sleep.

NIH is National Institute of Health.  The NIDCR is the National Institute of Dental and Facial Research who believes TMJ (TMD) is not related to occlusion but the NHLBI or National Heart Lung and Blood Institute  of the NIH wrote the report “Cardiovascular and Sleep Related Consequences of TemporoMandibular Disorders”  The HPA Axis is the Hypothalamus-Pituitary- Adrenal System that includes the reticular Activating System and is part of the Limbic system where we feel emotions.  Pain is an emotional response to noxious input.  Neuromuscular Dentistry addresses the HPA by stimulation of the SPG with ULF-TENS.  The is control of the autonomic nervous system with science .  This has been shown to increase permeability of the Blood Brain Barrier.…

TMJ Treatment: Across Illinois, Wisconsin and the Midwest

Dr. Shapira Blog 4 Comments

Why do patients travel long distances for TMJ treatment.
What I find is patients have had pain for years and think there is nothing else that can be done and then severity increases and they desperately look for an answer.

They want a comprehensive approach to diagnosis and treatment but most of all they want to QUICKLY IMPROVE THEIR QUALITY OF LIFE.

They come across a world of treatment different than what was ever discussed with their general dentist.

It turns out most dentists know very little about treating TMJ disorders beyond simple splints.

A small group of dentists become obsessed with knowing more and more about the condition and become more and more expert about very arcane little details.

The vast majority of patients get a night guard and simple habit changes and the TMJ problems are fixed. The difficult patients either learn to live with pain or end up seeking speciatly care.

There is no specialty in TMJ treatment so usually patients seeking specialty care first go to the oral surgeons (OS) office. This is appropriate for TMJ surgery but is the last place to go for occlusal therapy for TMJ problems because most OS never look at fine tuning occlusion. OS making splints that don’t work often look for surgical answers. The one rule in TMJ treatment is avoid TMJ surgery whenever possible.

So who are the TMJ Specialists? There is a group who want to create a specialty of Oral Facial Pain and have been denied specialty status by the ADA or American Dental Association so the are creating their own specialty board and declaring themselves specialists in oral facial pain a dangerous precedent but also rather pointless becaust they want to use the medical model of treating everything with drugs.

The real specialists are dentists who come together to study the intricacies of TMJ disorders. I often call them a small group of old doctors who learn more and more about less and less eventually knowing everything about nothing. Joking aside they delve very deeply into the most minute details.

I am currently the Chair of the Alliance of TMD Organizations and there are several groups who focus on different methods of treating the disorders.

I am a Fellow of the International College of CranioMandibular Orthopedics the Physiologic Group most dedicated to the underlying science involved in treatment utilizing physiologic dentistry protocols taught by the father of physiologic dentistry, Dr Barney Jankelson.

I am also a life member of the American Equilibration Society which is the oldest and largest TMJ treatment organization. They approach the disorder from a more mechanistic approach.

I always go to their annual meeting because I learn new aspects from doctors who approach treatment from a completely different approach. This group is also very focused on intricate details of treatment.

Both of these groups treat the same condition coming from a different direction. Doctors in both groups are successful.

The is another group the Academy of Craniofacial Pain (formerly academy of head neck and facial pain)who are very diverse in their approach. I would describe it as knowing less and less about more and more until they know nothing about everything (in jest) I am also a member of this group and I find they bring into the picture a wider scope of treatment possibilities.

Still another group is the American Academy of Physiological Esthetics (formerly American Academy of Comprehensive Esthetics) They are also a Physiologic Group affiliated with the Las Vegas Institute. They are very focused on physiologic Dentistry as approach to esthetic and full mouth reconstruction. LVI teaches a watered down approach to physiologic dentistry and the science but aree excellent (probably best) at hands on teaching of technique. They take a cookbook approach to Physiologic Dentistry and almost all of their work is based on scientific foundation of ICCMO and Barney Jankelson. I learned Physiologic Dentistry at ICCMO and from Barney Jankelson, Jim Garry, Barry Cooper, Dayton Krajiec and others at ICCMO but I learned to efficiently utilize it for Full Mouth reconstruction at LVIn for magnificent rehabilitations.

There are also orthodontic approaches to TMJ disorders as practised byInternational Association of Orthodontics, another excellent group primarily focused on orthodontics and secondarily on TMJ disorders but consider TMJ in all of their cases. This group is actively preventing development of TMJ disorders during orthodontic treatment.

The Sacral Occpital Chiropractic group, The Nucca Chiropractors, the At;as Orthoganol chiropractors and the Cranio/ Chirodontics group all integrate with dentists to trat TMJ disorders as part of full body function.

The field of Epigenetic Orthodontics is very new and is not yet represented by a group but ist is changing the method of treatment . I utilize Epigenetic Orthodontics routinely to finish TMJ cases after pain is resolved.

The Academy of Dental Sleep Medicine does not consider itself a TMJ organization because they treat sleep apnea. As a Diplomate of the organization I will clearly state this is their biggest failing. The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should have expertise in treating TMJ disorders.

The NHLBI (National Heart Lung and Blood Institute) of the NIH consider Sleep Apnea to be a TMJ disorder and wrote a paper “The Cardiovascular and Sleep Consequences of YTemporomandibular Disorders”

There are two other Organizations that, in my mind have lost their way to some extent in treatment philosophy, one is the American Academy of Pain Management of which I am a Diplomat and the other is the American Academy of OroFacial Pain. Both have moved into treating functional and structural problems with drugs rather than correcting the underlying physiological issues.

I am still a member of the American Academy of Pain Management but that group is no longer part of the TMD Alliance.…

What Is The Best TMJ Treatment in Chicago?

Dr. Shapira Unsorted 0 Comments

The Best treatment for a TMJ disorder is very dependent on the exact symptoms and causes of the TMJ disorder in a particular patient. Determining the best treatment for an individual patient is usually done during a face to face visit but I can give several guidelines here.

Link to over 100 patient video testimonials: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

Night Guard Treatment:

If you only have pain at night or just after awakening you are probably a good candidate for a Bruxism Appliance. These are designed to protect the teeth during nocturnal grind or bruxism.

This type of appliance is very effective for people who grind their teeth but can frequently cause more pain in patients who clench because it can createmore forces during clenching.

Clenching and grinding of the teeth during sleep is often associated with Sleep Disordered Breathing, including Snoring, RERA, UARS or Upper Airway Resistance Syndrome, Hypopnea or Apnea. These are dangerous conditions that can be made worse in some patients by a typical night guard.

Morning Frontal Headache and daytime tiredness are associated with sleep disordered breathing. Dentists trained in treating sleep disordered breathing can be found at AADSM.org .I have taught hundreds of dentists the basics of sleep apnea treatment.  Ideally, a diplomate of the American Board of Dental Sleep Medicine is your first choice.

The NHLBI or National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ Disorder.

ACUTE CLOSE-LOCK
Patients who have an acute close-lock of one or both TMJoints are Emergency patients. The wrong treatment can lead to permanent disability and the development of chronic pain syndromes.  Short term treatment is described below, long term stabilization will be discussed later.

An acute close-lock of one or both TMJoints can be evident upon wakening or may occur during the day. This is a type of Internal Derangement of the TMJoint. Patients who have chronic clicking or popping of one or both joints can have the disk get stuck anterior to the condyle of the mandible.

The symptoms for a unilateral close-lock of the TMJoint is reduced opening and sharp pain in the joint on the locked side. Attempting to open further gives increased pain and the jaw deviates to the side of the lock. If clicking was present previously it usually will be gone on the effected side.

The disk or meniscus is displaced and the condyle is pressing on the very delicate Retrodiscal Laminate. Trying to force the jaw open can permanently damage this important tissue.

Emergency Rooms are notorious for forcing the jaw open and causing increased pain and damage. For several years I taught emergency room physicians how to reduce close-lock dislocations. It is essential to support the jaw and prevent full closure or even a properly reduced joint can easily relock.

Many dentists and oral surgeons will place patients on a soft diet and prescribe non-steroidal anti-inflamatories such as Advil, Alieve or Aspirin. This is extremely risky approach to treating a close-lock. The longer the lock continues the more likelihood of permanent joint damage to the disk and retrodiscal lamina and the development of chronic pain.

The best approach is to reduce the dislocation as soon as possible and immediately supporting the bite with a temporary support to prevent recurrent locking. Unfortunately most dentists have no idea how to reduce a locked joint.  The reduction can be done with jaw manipulation either awake or sedated.  Acute close-lock can often be reduced easily by stimulation of specific reflexes in the jaw and pharynx.

Various appliances can be used to prevent damage and ease the reduction of more difficult locks these include unilateral pivotal splints for a lock in just one joint or a Rocobado spring loaded appliance for bilateral locks

Acute Open-Lock Dislocation or Subluxation

This is caused by a hyperextension of the jaw during opening.  It can happen from a yawn or biting ito very thick sandwich.  It can also occur immediately following a motor vehicle accident, usually being rear-ended.  It can also happen after difficult dental procedures and/or extractions especially of lower molars.

The condyle of the mandible actually moves out of the norman joint position and extends past the eminence where it gets stuck.  The patient will usually notice pain on the effected side and only 1 or 2 back teeth will touch on closing.  This tends to be frightening initially.This is again an Emergency, however this is easily treated at the ER in the hospital.

Patients with open locks need to learn not to hyperextend and to control maximum opening.  Prolotherapy can be used to tighten up the ligaments and tendons for a more stable joint that cannot hyperextend.  Surgery is another option usually best avoided.

Cheerleaders Joint

This is another condition that occurs frequently in cheerleaders, hence the name.  Shouting and cheering for a long time hyperextends the joint and it can create an open lock situation described above.  Sometime this will self reduce but there can be tremendous pain with jaw movement.  This is primarily muscle overuse pain and rest, stretching and anti-inflammatory medications is the best road.  It is vitally important to rule out close-lock and open lock conditions to avoid problems.

Post Dental Treatment:  Medial Pterygoid Myositis, Myalgia/Myosits

These conditions can occur following dental work and can be secondary to injections, inflammation joint or muscle tearing or stretching etc.

There is very little opening similar to a close lock but this is due to tight shortened muscles.  Time and anti-inflamatories can help.    There are variations of what is the cause, Muscle Splinting is a normal physiologic process where the muscles tighten up to protect an injured area.  Unfortunately, this can become chronic muscle shortening with muscle tightness, taut bands and trigger points.   Muscle Spasm is usually very painful but short in duration.  It is like a “Charlie Horse” of the jaw muscles.  Myositis is the slowest to resolve and is related to inflammatory changes in the muscle and can be quite painful.  Time, anti-inflamatories and stretching while icing helps.

FIBROMYALGIA AND MYOFASCIAL PAIN AND DYSFUNTION are two specific groups of muscle pain that must be included in this discussion of what is the best treatment.

All of the above conditions respond extremely well to Ultra Low Frequency TENS (ULF-TENS)  There are two units available for ULF-TENS the Myomonitor from Myotronics and and the BioTens from BioResearch.  No other TENS should be utilized.

These conditions also respond well to physical therapy, massage therapy and other manual techniques as well as ultrasound, interferential and micro current.  An Aqualizer Appliance ™ can be excellent short term treatment.

It is essential to determine if a close-lock internal derangement is also present.  Delay can lead to permanent damage.

Long-Term Chronic TMJ Dysfunction

TMJ is often called the Great Imposter due to the many associated symptoms that accompany the TMD

There are numerous types of appliances available including centric occlusion, centric relation and physiologic orthotics.  There is a specialized type of appliance called an NTI which has specific though limited uses.  Appliance can be made for the upper or lower arch.  Ideally, an appliance should always look and feel comfortable for 24/7 wear including for using while eating even if it is not to be worn all the time.  Frequently separate appliances are needed to treat sleep disorders breathing.

Doctors treating difficult cases should have additional training and expertise in a wide range of fields.  I suggest visiting doctors who are a Diplomate of The  American Academy of Pain Management and the American Board of Dental Sleep Medicine.  Physiologic Dentists should be member of ICCMO, the International College of CranioMandibular Orthopedics.  Centric relation dentists should belong to The American Equilibration Society though the best dentists belong to both groups and look at all aspects of treatment.

There are treatments that are often essential elements of complete treatment including management of trigger points with Spray and Stretch Techniques, Trigger Point Injections and /or manual techniques, Utilization of SPG or Sphenopalatine Ganglion  Blocks, and coordination with Specialists in dealing with the Occipital-Atlas-Axis joints, usually Atlas-Orthoganol or NUCCA Chiropracters or Osteopaths.

Jaw problems are related to breathing, airway and posture so experience in DNA Appliances is very helpful for TMD dentists.  Ideally, dentists treating TMJ disorders have a method of non-invasively seeing jaw function with computerized mandibular scans from Myotronics or BioResearch.

An absolute requirement of any doctor treating TMJ disorders is one who sets up time for  a consultation reviewing your medical history, evaluating what has previously been done and how it worked.  Your doctor should be able to clearly explain how all the different symptoms are related.  The best TMJ doctors can usually relieve muscle and headache pain temporarily while you are in the office, welcome your questions make you feel comfortable and never talk down to you.

The best TMJ Dentists are people you feel comfortable talking to.  The first visit will usually start in the consult room not the dental chair.  Acute close locks will usually quickly move to treatment room.  It is vitally important that you do not feel intimidated by your doctor, the best results occur when the patient and doctor work as a team to address problems.

Ideally, no permanent changes are made initially but rather treatment begins with a diagnostic orthotic. The goal of initial treatment is to relieve symptoms as quickly as possible and to understand the underlying etiology of the problem.  Equilibration of the teeth is usually avoided until the patient is comfortable and a treatment plan is accepted.  Wanton grinding on teeth can create new problems and it is hard to “ungrind a tooth”  That said, brand new dental work that caused the problem sometime may need adjustment.  The safest area of adjust is on the front teeth if they hit first but a diagnostic orthotic is still the best starting point.

Long term treatment should be discussed at the initial consultation but is only considered after resolution of pain and dysfunction.

VIDEO TESTIMONIALS:

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos