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

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Idiopathic Pain Relief: When Doctors Do Not Know The Cause of Your Pain How Do You Find Relief?

Dr. Shapira Chicago, Libertyville, TMJ 0 Comments

Idiopathic Pain essentially means “The Doctors are Idiots in determining the cause of your pain”.  This can be extremely discouraging as a patients.

Sometimes problems are diagnosed as idiopathic because the doctor is not familiar with the disorder you have.

These types of pain are often treated with a multitude of different medications on a trial and error basis.

There are some very safe and effective treatments for Idiopathic Pain anywhere in the body.  An excellent review of symptoms relievable by SPG Blocks can be found at: https://www.sphenopalatineganglionblocks.com/relief-wide-variety-eye-pains-spg-blocks.

Even problems like Fibromyalgia can  be addressed by SPG Blocks:  https://www.youtube.com/watch?v=A5xUFtuZe_Y

TMJ disorders have been called “The Great Imposter” because they can masquerade as many different types of problems and are usually misdiagnosed multiple times before being identified..  Most physicians other than ENT’s know very little about TMJ Disorders (TMD) .

Chicago TMJ Disorders: TMJ, “The Great Imposter” Amazing Patient Testimonials Videos Describe How Neuromuscular Dental Treatment

 

TMJ, Alias: the Great Imposter, has a Co-Conspirator: Poor Sleep: Orofacial Pain has Multiple Causes which require Differential Diagnosis.

Sinus Headache, Sinusitis, Sinus Pain and TMJ Disorders

Dr. Shapira Blog, Chicago, Highland Park, Lake Bluff, Lake Forest, Libertyville, TMJ, Uncategorized 0 Comments

Chronic Sinus Headache and other Sinus Pains are closely related to TMJ Disorders. The connections between these problems is multifacted.

The Trigeminal Nerve also called the Dentist’s Nerve is the underlying common source of all of these problems.

Dentists are the experts on the Trigeminal Nerrve Disorders and in particular neuromuscular dentists who optimize eliminating noxious input to the trigeminal system. The term “TMJ: The Great Imposter” was coinded because patients with TMJ disorders frequently report symptoms not specifically related to the joints.

Dentists who practice TMD and Neuromuscular Dentistry are well versed in Myofascial Pain and Dysfunction or MPD as it relates to upper body, head neck and facial pain referred from active myofascial trigger points.

The Sphenopalatine Ganglion (SPG), the largest parasympathetic ganglion in the head is on the maxillary division of the trigeminal nerve. I have taught hundreds of neuromuscular dentists both from the USA and from across the world how to utilize SPG Blocks as part of Neuromuscular Treatment.

The Sphenopalatine Ganglion also contains Sympathetic fibers of superior cervical change responsible for “Fight or Flight” reflex and when not controlled create a wide variety of stress, pain and emotional issues.

The Myomonitor utilized by Neuromuscular Dentistry effectively neuromodulates the sympathetic and parasympathetic autonnomic input from the Trigeminal Nervous System.

The majority of sinus pain and sinus headache are NOT primary issues or infections within the sinuses. Antibiotics may actually create new sinus issues related to fungal infections.

Sinus pain and Headaches can be relieved with SPG Blocks very quickly.

Long term sinus improvements are related to function and structure.  The following is a video of a patient who has experienced a cure of her lifetime sinus issues with DNA Appliance.  Neuromuscular Dentistry treated her TMJ disorders and the DNA is used for long term stabilization and to increase the size of her airway.

There are over 150 additional videos on treatment of TMJ Disorders, Headaches, Migraines, MPD, Fibromyalgia, Sinus pain, Sleep Apnea and snoring mat this link:  https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

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Acute Migraine: Sphenopalatine Ganglion Blocks (SPGB) Safe and Effective. Self Administration is a Patient Friendly Approach

Dr. Shapira Blog 0 Comments

A new article published in 208 discusses utilization of Sphenopalatine Ganglion Blocks for treatment of Severe Migraine.  Because it is published byty.the US National Library of Medicine of the National Institute of Health I can reprint it here.

I will make my personal comments in ALL CAPITAL LETTERS.  I ALSO FIND THAT SPG BLOCKS  CAN TREAT MANY OTHER DISORDERS INCLUDING FIBROMYALGIA, NECK, BACK, TMJ DISORDERS, TMD AND SHOULDER PAINS.

SELF-ADMINISTRATION OF SPG BLOCKS SHOULD BE CONSIDERED BY ALL PATIENTS WITH CHRONIC HEAD AND NECK PAIN, CLUSTER HEADACHES, ACUTE MIGRAINES, SINUS PAIN, SINUS HEADACHE AND EYE PAIN.  THIS DOES NOT MEAN THAT NEW PAIN SHOULD NOT BE EVALUATED BY APPROPRIATE PHYSICIANS AND SPECIALISTS.

INTRESTING NEW STUDIES HAVE SHOWN SPG BLOCKS ELIMINATING ESSENTIAL HYPERTENSION IN ONE THIRD OF PATIENTS.

. 2018; 2018: 2516953.
 Published online 2018 May 7.
Sphenopalatine Ganglion Block for the Treatment of Acute Migraine Headache

Abstract

Transnasal sphenopalatine ganglion (THE SPHENOPALATINE GANGLION IS ALSO KNOWN AS THE PTERYGOPALATINE GANGLION, MECKEL’S GANGLIO, THE NASAL GANGLION AND SLUDER’S GANGLION) block is emerging as is an attractive and effective treatment modality for acute migraine headaches, cluster headache, trigeminal neuralgia, and several other conditions.  We assessed the efficacy and safety of this treatment using the Sphenocath® device. 55 patients with acute migraine headaches underwent this procedure, receiving 2 ml of 2% lidocaine in each nostril. (2% LIDOCAINE HAS ANTIINFLAMATORY PROPERTIES AND HAS VERY FAVORABLE SAFETY PROFILE)  Pain numeric rating scale (baseline, 15 minutes, 2 hours, and 24 hours) and patient global impression of change (2 hours and 24 hours after treatment) were recorded. The majority of patients became headache-free at 15 minutes, 2 hours, and 24 hours after procedure (70.9%, 78.2%, and 70.4%, resp.). The rate of headache relief (50% or more reduction in headache intensity) was 27.3% at 15 minutes, 20% at 2 hours, and 22.2% at 24 hours. The mean pain numeric rating scale decreased significantly at 15 minutes, 2 hours, and 24 hours, respectively. Most patients rated the results as very good or good. The procedure was well-tolerated with few adverse events. This treatment is emerging as an effective and safe option for management of acute migraine attacks.  THE EXCELLENT AND RAPID RESPONSE IS EXTREMELY FAVORABLE HOWEVER PATIENTS MUST GO TO THE EMERGENCY DE3PARTMENT OR PHYSICIANS OFFICE TO BE TREATED.  A BETTER APPROACH IS TO TREAT THE PATIENTS TO SELF ADMINISTER THE BLOCKS TO STOP THE MIGRAINE EARLY OR PREVENT IT COMPLETELY IF THE BLOCK IS DONE DURING PRODROME.

THE SPHENOPALATINE GANGLION BLOCK WAS ORIGINALLY DESCRIBED BY SLUDER IN 1908.  DR GREENFELD SLUDER WROTE A TEXTBOOK NASAL NEUROLOGY AND BECAME CHAIR OF OTOLARYNGOLOGY AT WASHINGTON UNIVERSITY MEDICAL SCHOOL IN ST LOUIS.A   A 930 ARTICLE IN THE ANNALS OF INTERNAL MEDICINE BY HIRAM BYRD MD REPORTED ON 10,000 BLOCKS ON 2000 SEPERATE PATIENTS WITH VIRTUALLY NO ADVERSE EFFECTS.  UNFORTUNATELY, THE SPHENOPALATINE GANGLION BLOCK BECAME A VICTIM OF FORGOTTEN MEDICINE WHEN DRUG COMPANIES CREATED A STORM OF PHARMACEUTICALS.  THE SAFETY PROFILE OF THESE DRUGS DO NOT APPROACH THAT OF SPG BLOCKS WITH 2% LIDOCAINE.  A 1986 BOOK ‘MIRACLES ON PARK AVENUE” WAS PROBABLY RESPONSIBLE FOR THE GRADUAL RESURGENCE OF THIS EXCELLENT TECHNIQUE.  THE BOOK DESCRIBED THE NYC PAIN PRACTICE OF DR MILTON REDER AND ENT WHO UTILIZED ONLY SPG BLOCKS TO TREAT A WIDE VARIETY OF PAINFUL CONDITIONS REGARDLESS OF UNDERLYING DIAGNOSIS.

1. Introduction

Migraine is a common primary headache disorder, causing significant disability and personal, societal, and financial burden (SELF ADMINISTRATION OF SPG BLOCKS CAN SIGNIFICANTLY REDUCE COSTS IN TERMS OF EXPENSES, LOST WORK AND SUFFERING) []. It is a highly prevalent condition, affecting 11% of adult population worldwide, including people of all ages, races, geographical areas, and income levels []. Although there are currently many options for acute migraine treatment, such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDS), triptans, combinations analgesics, and antiemetics [], these treatment options are often (MORE OFTEN THAN NOT)  suboptimal, with inadequate efficacy and significant side effects []. In addition, several studies [] have shown that migraine patients with poor response to acute treatment are at increased risk for transformation to chronic migraine (CM) (SPG BLOCKS ARE ALSO EFFECTIVE AT TREATING CHRONIC MIGRAINE BUT EARLY INTERVENTION IS STILL THE BEST ROUTE) , with roughly 2.5-3.5-fold greater odds of developing CM []; patients with a moderate or better acute treatment efficacy did not have a significant increased risk. Therefore, there is a continuous need for new treatment modalities to address the therapeutic needs of migraine sufferers, especially those with frequent and disabling attacks [].

Sphenopalatine ganglion (SPG) block has gained interest as an effective treatment modality for migraine and other headache and facial pain syndromes []. SPG, also known as the pterygopalatine ganglion (PPG), is a large extracranial parasympathetic ganglion (THE SPG IS THE LARGEST PARASYMPATHETIC GANGLION OF THE HEAD)with multiple neural connections (Figure 1), including autonomic, motor, and sensory []. This complex neural structure is located deeply in the pterygopalatine fossa (PPF) posterior to the middle turbinate and maxillary sinus [], on each side of the face. The parasympathetic preganglionic cell bodies originate in the superior salivatory nucleus in the pons, and the parasympathetic fibers run in the nervus intermedius (a branch from the facial nerve) through the geniculate ganglion, forming the greater petrosal nerve (GPN). The sympathetic fibers originate in the superior cervical ganglion (THE SYMPATHETIC FIBERS OF THE SUPERIOR CERVICAL SYMPATHETIC CHAIN ARE VERY IMPORTANT IN THE ABILITY OF THESE BLOCKS TO TURN OFF THE “FIGHT OR FLIGHT” REFLEX) around the internal carotid artery and give rise to the deep petrosal nerve, which joins the GPN to form the Vidian nerve, which enters the SPG. The sensory input to the SPG is via branches from the maxillary nerve, carrying sensations from the palate, buccal cavity, gingival, and tonsils [].

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Saggital view of the nasopharynx, showing the sphenopalatine ganglion and its neural connections. Reproduced with permission from Robbins et al. (2016) [under the Creative Commons Attribution License number 4318850197898 (Wiley).

The parasympathetic fibers synapse in the SPG and second-order neurons provide secretomotor function to the mucous membranes of nose, mouth, pharynx, and lacrimal glands, as well as branches to the meningeal and cerebral blood vessels []. The sympathetic fibers pass through the SPG without synapsing and provide innervations to the palate, nasal cavity, and pharynx.

As acute migraine attacks, as well as other primary headache disorders like cluster headache, are often associated with signs of parasympathetic activation, including lacrimation, nasal congestion, and conjunctival injection, blocking the SPG, which is the major parasympathetic outflow to the cranial and facial structures, is a reasonable target to help relief pain and autonomic features seen in these disorders []. It is proposed that various migraine triggers activate brain areas related to superior salivatory nucleus, leading to stimulation of the trigemino-autonomic reflex. This results in increased parasympathetic outflow from the SPG, causing vasodilatation of cranial blood vessels that happens during migraine [], with the release of inflammatory mediators from blood vessels and activation of meningeal nociceptors, causing migraine pain []. Another possible effect of SPG block is modulation of sensory processes in the trigeminal nucleus caudalis via the afferent sensory fibers, which may change pain processing center and reduce central sensitization to pain that is commonly seen in migraine [].

SPG blocks have been used for the treatment of headache since a long time []. In 1908, Sluder described the use of transnasal SPG block using a long needle to inject cocaine, treating what was called Sluder’s neuralgia []. The technique was further developed by Simon Ruskin [], and in 1925 he used it to treat trigeminal neuralgia. Since then, the indications for SPG block have expanded to include cluster headache, migraine, trigeminal neuralgia, and many more [].

SPG blocks have been achieved with various techniques, including the use of lidocaine-soaked cotton tip applicator through the nose, transorally, transnasal endoscopic, infratemporal approach, and more recently using various noninvasive transnasal devices to inject anesthetics into the SPG [].

The objective of this study is to assess the efficacy of SPG block, using the Sphenocath device, for the treatment of acute migraine headaches in the outpatient setting. We also report the safety of this novel technique for migraine treatment.

2. Methods

2.1. Study Design and Setting

We conducted an open, uncontrolled, retrospective study in the neurology clinic at a university medical center. The patients were treated between March 2017 and September 2017. The study was approved by the institutional review board of University Medical Center at King Abdullah Medical City.

2.2. Study Population

The patients were recruited to the study if they were between 18 and 60 years of age, have been diagnosed with migraine headache according to International Classification of Headache Disorders-3 Beta [] since at least one year, and present with moderate to severe headache lasting between 4 and 72 hours not responding to abortive medications. Patients with medication overuse headache, bleeding disorders, abnormal neurological examination, and history of allergy to local anesthetics were not included in the study. All patients gave an informed written consent.

2.3. Methods of Measurement

Pain was assessed using numeric rating scale (NRS), where 0 is no pain and 10 is worst pain imaginable; this was recorded at baseline, 15 minutes, 2 hours, and 24 hours after the procedure. We also recorded patient global impression of change (PGIC; very poor, poor, no change, good, and very good) at 2 hours and 24 hours after procedure.

2.4. Outcome Measures

The primary efficacy measure was the percentage of patients free of headache at 15 minutes, 2 hours, and 24 hours after the procedure. Secondary endpoints were

  1. headache relief rate, defined as percentage of patients with 50% or more reduction in headache intensity at 15 minutes, 2 hours, and 24 hours;
  2. change in NRS from baseline to 15 minutes, 2 hours, and 24 hours after treatment;
  3. PGIC (effects on headache and its associated symptoms and tolerability) at 2 hours and 24 hours;
  4. all adverse events up to 24 hours after procedure.

Statistical analysis was done using SPSS Statistics Version 23.

3. Procedure

Prior to procedure, the nose was inspected for any obstruction, and xylometazoline 0.05% nasal drops( AFRIN NASAL SPRAY, OXYMETAZOLINE SPRAY IS EXTREMELY EFFECTIVE IN SHRINKING NASAL MUCOSAL TISSUES) ) (one drop in each nostril) were used to help open the nasal passages. Face temperature was recorded using temperature sensor skin probes put on both cheeks. A small amount of 2% lidocaine jelly was installed in each nostril for patients’ comfort, using a needless syringe. (AN ALTERNATIVE IS TO USE 2% LIDOCAINE IN A SPRAY FORM ONE MINUTE BEFORE PLACEMENT) Each patient received a single treatment of transnasal SPG block with 2 cc of 2% lidocaine in each nostril in the supine position with head extension, delivered using the Sphenocath device.  (I UTILIZE PRIMARILY A COTTON-TIPPED NASAL CATHETER THAT ALLOWS CONTINUAL CAPILLARY FEED OF LIDOCAINE FOR MOST PATIENTS.  I ALSO UTILIZE THE SPHENOCATH AND THE TX360 DEVICES IN MY OFFICE.  THE ALLEVIO DEVICE IS SIMILAR TO THE SPHENOCATH DEVICE) This is a small flexible sheath with a curved tip (Figure 2). It is inserted through the anterior nasal passage parallel to nasal septum and above the middle turbinate. Once in place, the inner catheter is advanced to administer 2 cc of 2% lidocaine. It is then removed and the procedure is repeated on the other side. Typically after the block, there is an increase in face temperature by 1 to 2 degrees Celsius and/or tearing []. The patient is instructed to remain in the same position for 10 minutes.  GENERALLY THERE IS LESS DISCOMFORT WITH THE COTTON TIPPED CATHETER BUT IN SOME PATIENTS WITH DIFFICULT ACCESS I UTILIZE DEVICE DELIVERY.

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ATERAL APPLICATIONThe Sphenocath device. Image provided courtesy of Dolor Technologies.

4. Results

55 patients received treatment with bilateral transnasal SPG blocks. 72.7% were females. The age range of patients was 19 to 58 years, with a mean age of 37.9 years. The baseline NRS range was 4 to 10, with a mean of 6.8. For the primary end point (headache freedom at 15 minutes, 2 hours, and 24 hours), the percentages were 70.9%, 78.2%, and 70.4%, respectively (Figure 3). Among the secondary efficacy measures, 27.3%, 20%, and 22.2% of patients reported headache relief at 15 minutes, 2 hours, and 24 hours after the procedure, respectively (Figure 3).  THE RAPID RELIEF IS TYPICAL OF PATIENTS RECEIVING SPG BLOCKS REGARDLESS OF THE METHOD OF DELIVERY.  THE COSTS OF THE DEVICES ARE HIGH APPROXIMATELY $75.00.  I PREFER THE COTTON-TIPPED NASAL CATHETERS WHICH COST LESS THAN $1.00 PER BILATERAL APPLICATION.  MORE IMPORTANT THEY ARE VERY EASY FOR MOST PATIENTS TO UTILIZE FOR SELF ADMINISTRATION AT HOME.

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The percentage of patients reaching headache freedom (pain numeric rating scale 0) and patients with headache relief (50% or more reduction in headache intensity), at 15 minutes, 2 hours, and 24 hours.

The mean NRS scores decreased significantly from a baseline of 6.8 to 0.9, 0.6, and 0.8 at 15 minutes, 2 hours, and 24 hours after procedure, respectively (Figure 4).

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The mean pain numeric rating scale at baseline and 15 minutes, 2 hours, and 24 hours after treatment, showing significant and sustained reduction in pain intensity.

Regarding PGIC, the majority of patients (98.1% at 2 hours, 98.1% at 24 hours) reported feeling very good or good (Figure 5). Only one patient reported “no change” in PGIC scale at 2 hours, but “very good” at 24 hours, and another patient rated her PGIC as “good” at 2 hours and “poor” at 24 hours due to return of headache which was slightly worse than before.

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Patient global impression of change after the procedure at 2 hours and 24 hours. The majority of patients rated the treatment result as very good or good.  PATIENTS SIMILARLY RATE RELIEF FROM TRANS-NASAL COTTON-TIPPED CATHETERS VERY HIGH.

Overall, the procedure was well-tolerated. Adverse events reported by the study population were mild (Figure 6), including transient throat numbness (100%), nausea (10.9%), dizziness (10.9%), vomiting (1.8%), nasal discomfort (18.2%), and worsening of preexisting headache (1.8%). These adverse events were transient and lasted less than 24 hours.  I RARELY SEE ADVERSE REACTIONS THOUGH THERE IS LIMITED COMPLAINTS ABOUT TASTE AND THROAT NUMBNESS BUT BECAUSE OF THE SLOWER DELIVERY THIS IS LESS OF A PROBLEM.  CHIEF COMPLAINT IS NASAL DISCOMFORT THAT CAN USUALLY BE ELIMINATED WITH AFRIN NASAL SPRAY AND LIDOCAINE SPRAY. THOSE SPRAYS.

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Adverse events recorded in the first 24 hours after the procedure.

5. Discussion

This retrospective case series demonstrated that transnasal SPG block with 2% lidocaine, using the Sphenocath device, is an effective and safe treatment for acute migraine headaches. There was a rapid relief of headaches observed at 15 minutes and 2 hours, and treatment effect was sustained at 24 hours after procedure in most patients. 70.9%, 78.2%, and 70.9% of patients were completely headache-free at 15 minutes, 2 hours, and 24 hours, respectively, while further 27%, 20%, and 27% achieved 50% or more headache relief at 15 minutes, 2 hours, and 24 hours, respectively. The majority of study population reported either very good or good response on PGIC at 2 hours and 24 hours.

A number of studies were published over the years regarding SPG blockade in acute migraine, with variable results []. Kudrow et al. [] conducted a noncontrolled study in migraine patients using 4% intranasal lidocaine and showed that 12 out of 23 patients achieved complete headache relief, and the effect was sustained at 24 hours. Maizels and Geiger [] evaluated the efficacy of 4% intranasal lidocaine as a treatment for acute migraine attacks, which was administered by the patient at home, in a double-blind, randomized controlled study. There was a significant reduction in headache severity at 15 minutes compared to placebo, but there was headache recurrence in 21% of patients receiving lidocaine.

Another placebo-controlled study compared outcomes for acute treatment of chronic migraine patients with intranasal 0.5% bupivacaine (n = 26) or saline (n = 12) using the Tx 360® device to block the SPG []. The injection was given twice a week for 6 weeks. The trial revealed significant reduction in pain numeric rating scores in the bupivacaine group at 15 minutes, 30 minutes, and 24 hours after each treatment. A randomized, double-blind, placebo-controlled study using intranasal bupivacaine or saline injections in patients presenting to the emergency department with acute frontal-based headache [specific classification was not required] demonstrated no significant difference in the proportion of patients achieving 50% or more headache relief at 15 minutes [].

Other studies used different agents for SPG blockade. For example, Bratbak et al. used onabotulinum toxin A injections into the SPG in 10 patients with intractable chronic migraine in an open, uncontrolled study []. This was done through a percutaneous infrazygomatic approach with a novel injection device. A statistically significant reduction of moderate and severe headaches was observed at 2 months after treatment; there were a total of 25 adverse events, mostly local discomfort, but none were classified as severe.

The SPG unique position in the PPF, as well as its multiple neural connections to sensory and autonomic systems involved in pain generation and propagation and the associated autonomic manifestations seen in many primary headache and facial pain syndromes, makes it a promising target for the treatment of these conditions. Inhibition of parasympathetic outflow from the SPG causes reduced activation of perivascular pain receptors in the cranial and meningeal blood vessels, with resultant reduction in the release of neuroinflammatory mediators (acetylcholine, nitric oxide, vasoactive intestinal peptide, substance P, and calcitonin gene-related peptide) from sensory fibers supplying the cranial and meningeal vasculature. This, in turn, reduces pain intensity and intracranial hypersensitivity observed in migraine [].

In our study, SPG blockade produced a rapid relief of headache at 15 minutes, with a significant treatment effect observed at 24 hours and high patient satisfaction. In general, the treatment was well-tolerated. We recorded few adverse events, which were mild and transient, similar to those seen in previous studies [].

The main limitation of our study included the lack of a placebo group, as subjective pain response might have a significant placebo component []. However, the high treatment response and satisfaction rates in this study were both encouraging and clinically meaningful for our patients. We did not assess the use of analgesics after two hours of receiving the SPG block, which might have influenced the headache relief percentage at 24 hours. However, this is allowed in acute headache trials guidelines [].

6. Conclusion

Transnasal SPG blockade is emerging as an effective and safe option for the treatment of several disabling headache and facial pain conditions such as migraine, cluster headache, and trigeminal neuralgia. Its ease of administration using noninvasive devices, safety profile, and quick pain relief makes it an attractive treatment option for these conditions. More well-designed studies are needed to further explore the efficacy of this treatment modality and its use as part of a comprehensive headache management program.

Conflicts of Interest

The authors report no conflicts of interest related to this paper.

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19. Candido K. D., Massey S. T., Sauer R., Darabad R. R., Knezevic N. N. A novel revision to the classical transnasal topical sphenopalatine ganglion block for the treatment of headache and facial pain. 2013;16(6):E769–E778. [PubMed]
20. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders. 2013;33(9):629–808. doi: 10.1177/0333102413485658. 3rd edition. [PubMed] [Cross Ref]
21. Wasserman RA., Schack T., Moser SE., Brummett CM., Cooper W. Facial temperature changes following intranasal sphenopalatine ganglion nerve block. 2017;3(5):p. e354.
22. Kudrow L., Kudrow D. B., Sandweiss J. H. Rapid and Sustained Relief of Migraine Attacks With Intranasal Lidocaine: Preliminary Findings. 1995;35(2):79–82. doi: 10.1111/j.1526-4610.1995.hed3502079.x. [PubMed][Cross Ref]
23. Maizels M., Geiger A. M. Intranasal lidocaine for migraine: A randomized trial and open-label follow-up. 1999;39(8):543–551. doi: 10.1046/j.1526-4610.1999.3908543.x. [PubMed] [Cross Ref]
24. Cady R., Saper J., Dexter K., Manley H. R. A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with Tx360® as acute treatment for chronic migraine. 2015;55(1):101–116. doi: 10.1111/head.12458. [PMC free article] [PubMed] [Cross Ref]
25. Schaffer J. T., Hunter B. R., Ball K. M., Weaver C. S. Noninvasive Sphenopalatine Ganglion Block for Acute Headache in the Emergency Department: A Randomized Placebo-Controlled Trial. 2015;65(5):503–510. doi: 10.1016/j.annemergmed.2014.12.012. [PubMed] [Cross Ref]
26. Bratbak D. F., Nordgård S., Stovner L. J., et al. Pilot study of sphenopalatine injection of onabotulinumtoxinA for the treatment of intractable chronic cluster headache. 2015;36(6):503–509. doi: 10.1177/0333102415597891.[PMC free article] [PubMed] [Cross Ref]
27. Diener H. C., Schorn C. F., Bingel U., Dodick D. W. The importance of placebo in headache research. 2008;28(10):1003–1011. doi: 10.1111/j.1468-2982.2008.01660.x. [PubMed] [Cross Ref]
28. Tfelt-Hansen P., Pascual J., Ramadan N., et al. Guidelines for controlled trials of drugs in migraine: Third edition. A guide for investigators. 2011;32(1):6–38. doi: 10.1177/0333102411417901. [PubMed] [Cross Ref]

Dr Shapira Awarded Diplomate Status with American Board of Sleep and Breathing. Currently in Boston Learning Advance Pain Management at Harvard Medical School.

Dr. Shapira Blog, Lake Forest, Sleep, TMJ 1 Comment

I am pleased to announce that I am now a new Diplomate of the American Board of Sleep and Breathing. I am a long term Diplomate of the American Board of Dental Sleep Medicine, Credentialed by the Sleep Disorder Dental Society (SDDS) and a Founding member of both the SDDS (Now AADSM) and Dosa , the Dental Organization for Sleep Apnea.

I did research into jaw position and sleep apnea as a visiting Assistant Professor at Rush Medical School from 1985 until 1991 and returned as an Assistant Professor from 1998 until 2001.  I had the pleasure of  working with Dr Rosalind Cartwright who was responsible for the growth of Dental Sleep Medicine.

I am currently in day two of my Harvard Medical School course on Advanced Pain Management. I am spending all of this week in Boston to improve on my skills in pain management.

The program is on Advanced Pain Management continuing Education with Academy of Integrative Pain Management and Harvard Medical School’s Top Pain Doctors.

Updates and Practice Recommendations to
Optimize the Assessment and Treatment of Pain
Headache, Fibromyalgia, Neuropathic, Myofascial, Cancer, Abdominal, Pelvic, Musculoskeletal, Spinal Pain.

https://americansleepandbreathingacademy.com/

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.

Management of Orofacial Pain with Sphenopalatine Ganglion Blocks

Dr. Shapira Uncategorized 0 Comments

Rapid treatment of Orofacial pain is very important because of the deleterious effects on your quality of life. According to an article in Cranio (abstract below) Journal SPG Blocks are “Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.”

Orofacial pain is often related to the autonomic nervous system. The lack of homeostasis or balance between the sympathetic division and the autonomic division division of the autonomic system often leads to problems with anxiety, stress overload, panic attacks and other Axis 2 events involving the limbic system.

The Limbic system is where we feel both good and bad emotions as well as pain. Pain is an emotional response secondary to nociceptive input to the brain.

Sympathetic overload is a common element of all orofacial pain patients. Many patients in chronic stress end up in a constant state of reflex “fight or Flight”

SPG Blocks or Sphenopalatine Ganglion Blocks are often rapidly effective in decreasing Orofacial Pain conditions. Utilization of a diagnostic neuromuscular orthotic often gives almost immediate relief. though some groups object to occlusal changes even when they dramatically improve patients quality of life.

Combination of these two treatments can give rapid dramatic improvement. Self-Administration of SPG Blocks is especially important in orofacial pain patients due to strong emotional effects of this type of pain.

Over 100 video orofacial pain testimonials: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

Shimshak showed in his lanfmark study that orofacial pain patients who carry TMJ diagnosis have a three fold increase in utilization of medical services in all fields of medicine. Side effects and costs of orofacial pain are enormous as is their effect on Quality of Life.

Sphenopalatine Ganglion Blocks
Cranio. 1995 Jul;13(3):177-81.
Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.
Peterson JN1, Schames J, Schames M, King E.
Author information
Abstract
The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.…

Orofacial Pain, Myofascial Pain and Chronic Headaches: Why Neuromuscular Orthotics Relieve Headaches.

Dr. Shapira Uncategorized 0 Comments

I am continuing looking at Orofacial Pain and actually checking the references used in the paper “Orofacial pain management: current perspectives” from Pain Res. 2014; 7: 99–115.

This paper will focus on an article cited “Myofascial Pain Syndrome as a Contributing Factor in Patients with Chronic Headaches” that concludes “Subjects with chronic headaches had a higher prevalence of TrPs, and headache complaints could be reproduced during stimulation of active TrPs that were localized more frequently in temporalis and occiptofrontalis muscles. The presence of TrPs may be a contributing factor in the initiation and/or perpetuation of chronic headaches.”

This is a paper about Orofacial Pain looking at Chronic Headaches and Myofascial Trigger Points. It specifically looks at occipital frontal and temporalis muscle trigger points. The Temporalis muscle overlies much of the occipitalfrontal muscle and is typically the initiating cause of dysfunction. Travell described the formation of myofascial trigger points as due to overuse syndromes also called repetitive strain injuries.

This study found that 77% of the headache patients had myofascial trigger points and 89$ of these had active trigger points that could cause referred headache.

The first conclusion should most definitely be “Subjects with chronic headaches had a higher prevalence of TrPs, and headache complaints could be reproduced during stimulation of active TrPs that were localized more frequently in temporalis and occiptofrontalis muscles. The presence of TrPs may be a contributing factor in the initiation and/or perpetuation of chronic headaches.”

This paper should definitively settle the question whether trigger point examination should be done in all headache patients, the answer is an unqualified YES.

The second question is whether therapy in orofacial pain patients with headaches should address these trigger points, and again an unqualified YES.

The third question is if an oral appliance can prevent and help eliminate these trigger points and the related orofacial pain should it be used? Again the only answer is YES.

Should this be just a night “stabilization appliance” of a 24 hour orthotic? This is a question that needs to be addresed with the patient. There is some risk involved in an anterior positioning neuromuscular appliance. They are extremely successful (see https://thinkbetterlife.com/orofacial-pain-management-current-prospectives-patients-deserve-care-relieves-pain/)

Does the patient have a right to demand the best treatment to improve their quality of life? YES

Do patients need to be informed of risks? Yes

Diagnosis in 100 % of headache ptuients should include trigger point evaluation. All patients with trigger point invoked headaches from masticatory muscles should be offered both stabilization appliances and the more effective anterior positioning appliance. In my experience the best orthotics are produced via neuromuscular dentistry including muslce relaxation with ULF-TENS and computerized measurements.

This link leads to multiple patient testimonials of the effectiveness of nueromuscular diagnostic orthotics. Orofacial Pain Testimonials on Reddit utilizing neruomuscular dentistry: https://www.reddit.com/r/NeuroMuscularDent/

The following is a remark by me on the TMJ/TMD Facebook Discussion Group.
Ira L Shapira This is another article by Fricton (abstract) He says “pathologic and functional processes in the masticatory muscles. ” Functional processes could be restated as “occlusal function” You will notice that he does not include in his treatment protocol correcting functional problems from occlusion but does state.”reduction of contributing factors” I wrote a brief piece on this as well: https://thinkbetterlife.com/orofacial-pain-myofascial…/ Dent Clin North Am. 2007 Jan;51(1):61-83, vi.
Myogenous temporomandibular disorders: diagnostic and management considerations.

Fricton J1.
Author information
Abstract
Myogenous temporomandibular disorders (or masticatory myalgia) are characterized by pain and dysfunction that arise from pathologic and functional processes in the masticatory muscles. There are several distinct muscle disorder subtypes in the masticatory system, including myofascial pain, myositis, muscle spasm, and muscle contracture. The major characteristics of masticatory myalgia include pain, muscle tenderness, limited range of motion, and other symptoms (eg, fatigability, stiffness, subjective weakness). Comorbid conditions and complicating factors also are common and are discussed. Management follows with stretching, posture, and relaxation exercises, physical therapy, reduction of contributing factors, and as necessary, muscle injections.…

Orofacial Pain Management: Current Prospectives. Do All Patients Still Deserve Care That Relieves Their Pain?

Dr. Shapira Uncategorized 0 Comments

Treatment of Orofacial Pain can be complex and there are many issues that are both medical and dental in nature.

There is hope and this paper gives one clear example of what is wrong with many of the concepts of the Orofacial Pain Group that tends to discount valuable treatments with good scientific evidence.

One important concept in Orofacial Pain is the concept of MMI or Maximum Medical Improvement ie, this is the best results possible. This is an escape clause for doctors who do not have the expertise or knowledge to move their patients to a better quality of life or further reduction of symptoms. Very often the best treatment for a patient may never be offered. An example of this problem can be found in the conclusions of this paper from J Orofac Pain. 2010
“Systematic review and meta-analysis of randomized controlled trials evaluating intraoral orthopedic appliances for temporomandibular disorders.” By Fricton et al. which concluded that; “Hard stabilization appliances, when adjusted properly, have good evidence of modest efficacy in the treatment of TMJD pain compared to non-occluding appliances and no treatment. Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain. However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.”

Dr Fricton found that hard stabilization splints had “modest efficiency “compared to non-occluding appliances and no treatment” He also states that “Other types of appliances, including soft stabilization appliances, anterior positioning appliances, and anterior bite appliances, have some RCT evidence of efficacy in reducing TMJD pain.” One would assume when dealing with patients in pain that success alleviation of pain would be paramount but Dr Fricton actually finishes the conclusion stating “However, the potential for adverse events with these appliances is higher and suggests the need for close monitoring in their use.” This does not mean don’t use them but that use carries some risk. A patient in pain has the right to decide if that is a risk he or she wants to take. The problem is due to the politics of the AAOP patients are actually losing their right to the most efficacuos treatments.

This video is of a patient treated at Mayo Clinic who was told there was “NO HOPE” and was condemned by a neurologist at to a lifetime of pain. I utilized an appliance that “carried some risk of adverse consequences” but worked out very well for this patient. https://www.youtube.com/watch?v=IOJTPQEGr1w

Had we followed the satndard protocol of Orofacial Pain this patient was condemned to a “Lifetime of Pain and No Hope!”

Instead, she took advantage of a more efficacous and now lives pain free.

Yes, there are randomized Controlled Studies showing efficacy but even if there were only testimonials and clinical histories she has a right to chose her own fate.

We know that the third leading cause of death in this country is medical mistakes according to a study by Johns Hopkins.

Is the leading cause of pain in TMJ patients due to mistakes of non-treatment rather than overtreatment? …

Orofacial Pain and TMJ Disorders: Specialty?

Dr. Shapira Uncategorized 0 Comments

There is currently no specialty in Orofacial Pain and the American Dental Association does not believe one is needed. That does not mean that orofacial pain is not a problem, it is.

Most orofacial pain is actually well treated by the dental community. The most common causes of orofacial pain are related to teeth, gums dental abscesses, pulpitis and other disorders routinely treated by general dentistry. Sometimes non-dental pain is mistakenly treated as dental pain. The most common example is referred pain from muscles mistakenly treated as pulpitis pain and patients having root canal treatment preformed but the pain continues or moves to another tooth. I have seen patients with very healthy mouths with multiple teeth having had root canal treatment due to this type of misdiagnosis,

The second most common cause of orofacial pain is TMJ disorders which include Myofascial Pain, TM Joint internal derangements, capsulitis and tendonitis. These are commonly related to the bite, stress and parafunction, particularly night-time bruxism.

The majority of these problems are handled by a simple night-time bruxism appliance.

The more complicated TMJ disorders usually include multiple facets and affect not just the the oral structures but all of the muscles and nerve connections of the head and neck as well as the postural chain. They are not limited to the nerves of the somatosensory nervous system but are also firmly rooted to the sympathetic and parasympathetic divisions.

Typically dentists with advanced training in the treatment of TMJ disorders are very good at the differential diagnosis of orofaxial pain, particularly neuromuscular dentists.

Most of the chronic pain related to TMJ disorders is Myofascial Pain as described by Janet Travell in her landmark book; “MYOFASCIAL PAIN AND DYSFUNCTION: A TRIGGER POINT MANUAL” This ptype of pain is relatively easy to treat once it is understood that the problem is basically a repetitive strain injury.

Treatment of this Myofascial Pain and associated TM Joint pain usually involves utilization of a diagnost neuromuscular orthotic as part of the diagnostic process.

There are many other more infrequent and obscure conditions that fall under the umbrella of orofacial pain. Most of these are best treated by neurologists, ENT’s and Opthamologists. The push for an orofacial pain specialty is from a small group of doctors who think they are better equipped than the current medical specialties in doing differential diagnosis and treatment.

Differential diagnosis is the key to successful treatment. Dentists treating TMJ disorders need to understand this concept.
This link is to Chronic TMJ and Orofacial Pain Patients discussing treatment:
https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/playlists

There are groups in dentistry that are currently suing state boards to try to create a specialty denied by the American Dental Association, these are self appointed specialists.…