The trigeminal cardiac reflex (TCR) is a unique, powerful, and well-established neurocardiogenic reflex that is a result of stimulation along the path of the fifth cranial nerve (trigeminal nerve). It can produce adverse cardiorespiratory changes including hypotension, bradycardia, and asystole, as well as gastric consequences such as hypermotility. This reflex has been reported to occur in various surgical conditions, as well as in neurosurgical interventions.
Sleep bruxism, thought to be a more intense form of rhythmic masticatory muscle activity, has a prevalence of about 8%1 and has been explicitly linked to the TCR.2We report a case of a young woman with severe bruxism who incited her TCR, which subsequently produced profound nocturnal pauses that ultimately required dual-chamber pacemaker implantation.
A 27-year-old woman presented with palpitations and syncope. Three years prior to presentation she developed nocturnal and early morning nausea and vomiting that would often wake her from sleep. She was noted to have a long-standing history of severe bruxism with physical signs on examination of significant attrition. This had persisted despite the use of a retainer and bite block. Evaluation with Holter monitoring revealed sinus bradycardia, intermittent second-degree type II atrioventricular (AV) block, and a pause of 8.6 seconds (Figure 1). Interestingly, the rhythm strips showed simultaneous effects on both the sinus and AV node, suggesting an autonomic etiology. Of note, these rhythm disturbances were principally nocturnal in nature. While she was wearing the Holter, the husband was awake and corroborated that she was having severe episodes of bruxism. Further cardiac evaluation was unrevealing, including a normal echocardiogram, cardiac magnetic resonance imaging, sleep study, and thorough autonomic testing. With her constellation of symptoms—severe bruxism, AV nodal block with cardiac pauses (that were predominantly nocturnal), and gastrointestinal symptoms—we diagnosed her with hypervagotonia from stimulation of the powerful TCR from severe bruxism (Figure 2). Out of concern for risk of cardiac death from these pauses without a stable ventricular escape, we elected to place a dual-chamber pacemaker for bradycardic prevention.
This case highlights the intricate and noteworthy relationship between the autonomic nervous system and the heart. Our patient developed high-grade AV block and syncope owing to significant and profound hypervagotonia. Based upon her evaluation and corroboration of these events by her husband, we deemed that her intense vagal stimulation was a consequence of her severe bruxism, which was eliciting the TCR.
The TCR (Figure 2) is a powerful brain stem reflex that can be associated with a sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, or gastric hypermotility. The proposed mechanism of this reflex is stimulation of the sensory nerve endings of the trigeminal nerve (Figure 2, cranial nerve V), which sends signals via the Gasserian ganglion (Figure 2, indicated by asterisk) to the sensory nucleus of the trigeminal nerve (Figure 2 inset). The afferent pathway then continues along the short internuncial nerve fibers in the reticular formation to connect with the efferent pathway, the motor nucleus of the vagus nerve (Figure 2, cranial nerve X). The last part of the reflex is formed by cardioinhibitory efferent fibers, which connect the motor nucleus of the vagus nerve to the myocardium.3
Bruxism is a common occurrence in the population (8%) and has been associated with alterations in the autonomic nervous system and stimulation of the TCR.2, 4, 5, 6 The mechanism behind the TCR stimulation is felt to be 2-fold. Firstly, masticatory movements (rhythmic masticatory muscle activity) and secondly, teeth contact can stimulate mechanoreceptors in the periodontal tissue.7 The link between bruxism, TCR, and alteration in the autonomic nervous system is important to highlight as it is well established that the autonomic nervous system plays a critical role in the pathogenesis of various cardiac arrhythmias, particularly atrial fibrillation. Although not specifically related to our patient, the fact that bruxism is so common raises the potential role it could be contributing to autonomic drivers of atrial fibrillation, and this is something that requires further research examination.
2. Schames S.E., Schames J., Schames M., Chagall-Gungur S.S. Sleep bruxism, an autonomic self-regulating response by triggering the trigeminal cardiac reflex. J Calif Dent Assoc. 2012;40:670–671. 674–676. [PubMed]
3. Arasho B., Sandu N., Spiriev T., Prabhakar H., Schaller B. Management of the trigeminocardiac reflex: facts and own experience. Neurol India. 2009;57:375–380. [PubMed]
4. Gastaldo E., Quatrale R., Graziani A., Eleopra R., Tugnoli V., Tola M.R., Granieri E. The excitability of the trigeminal motor system in sleep bruxism: a transcranial magnetic stimulation and brainstem reflex study. J Orofac Pain. 2006;20:145–155. [PubMed]
5. Chowdhury T., Bindu B., Singh G.P., Schaller B. Sleep disorders: is the trigemino-cardiac reflex a missing link? Front Neurol. 2017;8:63. [PubMed]
6. Sjoholm T.T., Piha S.J., Lehtinen I. Cardiovascular autonomic control is disturbed in nocturnal teethgrinders. Clin Physiol. 1995;15:349–354. [PubMed]
7. Okada Y., Kamijo Y., Okazaki K., Masuki S., Goto M., Nose H. Pressor responses to isometric biting are evoked by somatosensory receptors in periodontal tissue in humans. J Appl Physiol. 2009;107:531–539. [PubMed]
DNA and RNA Appliance are used to Treat a wide variety of issues including TMJ disorders, Headaches, Migraines, Snoring and Sleep Apnea. Postural disorders to impaired breathing can be related to chronic head and neck pain and spread postural issues throughout the body.
It is vitally important for dentistry and medicine to address the development of airway issues that last a lifetime. I primarily work with older children, adolescents and adults in my practice. Children, even very young children receive the biggest benefit from expansion of airways. The DNA/RNA Appliance gives an important second chance to patients who did not properly develop as children. Adults can now be treated without orthognathic surgery, tongue reduction and other invasive procedures.
The DNA Appliances are changing the field or dental orthodontics from cosmetic shifting of teeth in available bone into the field of Epigenetic Orthopedics correcting problems that conventional orthodontics never addressed.
Orthodontics utilizing braces and brackets or plastic aligners as used by Invisalign, Smile Direct and other systems is about moving the teeth in the available bone to create a prettier smile and straighter teeth. Phased orthodontics in children has to a small extent embraced expansion of bone to create more space to straighten the teeth. Airway has only been minimally addressed by most of orthodontics.
There are many orthodontists who still practice “Contraction Orthodontics” also known as “Four on the Floor” or Bicuspid Extraction cases. The thought process is the you “Amputate” the teeth to make room in the mouth for all of the remaining teeth. This Contraction Orthodontics” makes the teeeth fit but crowds the tongue and impairs breathing.
Unfortunately, until recently the question of airway and ideal development of the jaws has not been addressed. There have been major changes in the last few hundred years to patterns of orofacial and cranial bone growth. These are negative epigenetic changes due to environmental issues including pollution, changes in how babies are fed and nurtured as new borns ant throughout their early lives. This has led to a massive problem of underdeveloped maxillas, mandiibles and airways.
I became involved in the early 1980’s in managing airway in adults by treating sleep apnea and snoring. I saw my son Billy had issues but when he was ready to start Kindergarten he was evaluated and I was told he had ADD, ADHD, could not start Kindergarten and needed to be on
Ritalin for life. You worry about your child’s when they cannot start kindergarten and I refused the diagnosis and took Billy to Rush Medical School for a sleep study. He had severe sleep apnea and we proceeded to have tonsils and adenoids removed and at 5 orthopedic expansion of hist maxilla. He had a tongue and lip tie corrected as well. He became a straight “A” student, went from 50% growth curve to 90% growth curve, slept well and mood was vastly improved. He graduated college double major, double minor Magna Cum Laude, His drug of choice was Oxygen not Ritalin. I became a Visiting Assistant Professor at Rush Medical School Sleep Center in 1985 and did research into similarities in jaw position in sleep apnea patients and TMJ patients.
Breast feeding is a major factor in the development of proper facial form. “Form follows function” is a truth in medicine and the changes in how babies are fed and nurtured has changed, which changes their development. These changes in growth and development affect airway and sleep, intelligence and learning and most importantly brain development and function and can lead to learning and behavioral disorders including ADD, ADHD and ODD. Many of these disorders are related to sleep disordered breathing including snoring, increased upper airway resistance syndrome (UARS), Respiratory effort related arousals (RERA) Hypopnea, Sleep Apnea.
The underdevelopment of the nasal oropharyngeal airway is the single biggest culprit and creates problems not just in infants, children and adolescents but also problems that last a lifetime. Sleep Apnea can cause issues with insulin resistance, memory loss and dementia, they cause a 300-600% increase in heart attacks and strokes as well as motor vehicle accidents, are implicated in hypertension, metabolic syndrome and obesity. Ideally a narrow airway is corrected before 8 years of age and it was thought expansion was limited if not impossible in adolescents and adults. The DNA Appliance has changed all that and expansion is possible throughout your life.
The DNA Appliance is an FDA approved orthodontic device that can often correct all of these issues. The RNA version of the
DNA Appliance is an FDA approved Sleep Apnea Appliance. Both the DNA and RNA Appliance utilize Epigenetic Orthopedics to grow larger airways and offer the possibility of curing sleep disordered breathing in all forms. The process of growing a larger airway has been called Pneumopedics by Dr David Singh who invented the DNA Appliance.
I will present several video testimonials of patients who have utilized the DNA/RNA Appliances. The first one is a patient experiencing major improvement in nasal breathing after just a few months of treatment. When the maxilla is expanded the roof of the mouth widens and high palates correct themselves flattening out. The hard palate is the roof of the mouth but that same bone is also the floor of the nose. With epigenetic expansion the cross section of the nose dramatically increases in both height and width. The expansion of the mouth makes more room for the tongue.
Nasal breathing increase the amount of Nitric Oxide the body produces which is the single most powerful antioxidant known. A Nobel prize has been given for work on Nitric oxide.
Sleep Apnea is a serious medical issue for millions of Americans. There are many treatments available to treat Sleep Apnea, the best known treatment is CPAP or Continuous Positive Airway Pressure which uses a compressor to deliver pressurized air through the nose and/or mouth through a mask. CPAP is extremely effective when it is used by patients but only about one in four patients prescribed CPAP actually use it on a regular basis. The 25% of patients who utilize CPAP is dwarfed in number by the 60% of patients who reject or fail CPAP completely. Approximately 15% try to manage CPAP but do poorly. Success is not the norm with CPAP in spite of the fact that it is extremely effective when used and is considered the “Gold Standard” of treatment.
The primary reason patients don’t use CPAP is that they “Hate CPAP”. Oral Appliances are also extremely successful at treating Sleep Apnea and are considered a first line approach for mild to moderate sleep apnea and an alternative to CPAP for severe sleep apnea. They are under prescribed primarily due ignorance in the medical community about effectiveness. CPAP is a billion dollar industry that has tremendous monetary power and thee makers of CPAP machines also make much of the diagnostic instrumentation for sleep.
The website https://www.IHATECPAP.com is an excellent resource to learn more about Sleep Apnea diagnosis and treatment. The name of the website is from patients who when asked why the wanted an oral appliance would commonly reply “I HATE CPAP!”
The following is a video of a physician describing his experience with an oral appliance to treat sleep apnea. Many physicians choose not to utilize CPAP but rather a comfortable oral appliance. Oral Appliances are excellent for managing Sleep Apnea but the DNA/RNA Appliances offer a “CURE”! Patients with sleep apnea must have their sleep apnea treated but it can be managed for a lifetime without negative consequences.
The following video is a physician whose life was affected by her sleep apnea and who chose to seek a cure for her apnea rather than just a treatment. She has not completed treatment at the time this video was made. Prior to treatment she was living in a state of exhaustion. The RNA Appliance is acting as both a sleep appliance and is growing her airway orthopedically. When the DNA/RNA Appliance is used to cure sleep apnea it actually results in a 24/7 improvement in airway not just a correction during sleep. This patient discusses oral Myofunctional Therapy which can aid in expansion and ideally should be utilized in every single orthodontic treatment. More important pediatric dentists and physicians should learn to be aware of these developmental issues and address them as soon as possible to prevent future issues. In retrospect, my son would have been far better off having his airway issues treated far earlier. Brain development is changed by sleep apnea even in infants and very young children.
TMJ Disorders, Chronic Headaches and Migraines and other types of Orofacial pain are often associated with airway issues. The National Heart Lung and Blood Institute published a report “The cardiovascular and sleep related consequences of TMJ disorders” The NHLBI of the NIH considers Sleep Apnea to be a TMJ disorder. The DNA Appliance is often utilized as a second phase of treatment for patients with TMD. The following is a patient who has lived her entire life with an underdeveloped maxilla and is using the DNA/RNA appliance to pneumopedically grow a larger airway and orthopedically grow her maxilla in order to treat her TMJ disorder. While she is still early in treatment she feels that her TMJ disorder has been cured. Her lower jaw (mandible) was locked in a posterior position and maxillary expansion has given it freedom to move forward and relieve abnormal pressure in the TM Joints
The next video is a patient who has lived with chronic head and neck pain for many years and initially was treated with a neuromuscular dental orthotic and is now utilizing the DNA Appliance to complete her treatment (Phase 2 ). She describes a wide variety of improvements after wearing the DNA Appliance for a couple of months. When you breathe better and correct airway issues it has positive effects throughout the entire body.
The next video is a patient who has had a lifetime of sinus issues and TMJ issues. While here TMJ issues were dealt with her small airway would create a less stable result and relapse. The DNA Appliance is being utilized to increase her airway and led to dramatic improvements in he sinus issues. Listen as she discusses how improved breathing is improving all aspects of her life.
Shimshak et al published a paper in Cranio Journal in 1998 looking at medical expenses in patients with TMJ disorders and found that there was a 300% increase in medical expenses in every single field of medicine. We now know that sleep and airway are very closely related and that the increase in medical expenses has many causes but treatment with the DNA Appliance addresses a wide spectrum of these issues. I wrote an article for Cranio Journal in 2013. The full ediitorial can be found at https://www.tandfonline.com/doi/pdf/10.1179/crn.2013.001?needAccess=true. I was asked to write this editorial by Riley Lunn tthe editor of
Cranio Journal because I had been treating sleep and airway issues since 1982 long before most of medicine or dentistry ever looked at airway and sleep apnea.
TMJ Alias, The Great Imposter, Has a Co-Conspirator: Poor Sleep
The next patient is much younger and his parents who are both Chiropractors brought him in to address airway issues that were leading to forward head posture and was affecting his posture in his entire body. Chiropractors are very aware of how head and jaw position affect the entire body.
The DNA Appliance is giving three dimensional expansion and there is a cascade of positive outcomes that occur as airway improves.
The next video is of Lewis who is now utilizing his RNA Appliance instead of CPAP while he is growing a larger airway. He appreciates being able to go camping with his appliance, something he could not do with CPAP.His teeeth have straightened out and he has a bigger better lower jaw.
The DNA and RNA Appliance utilize Epigenetic Orthodontics which is the single most exciting advancement in dentistry today. While it is called epigenetic orthodontics a more accurate name would be epigenetic orthopedics because it actually grows and reshapes and idealizes the bone rather than just move the teeth. This is far different than typical orthodontics.
This technological advances of the Vivos System allows us to comfortably create (grow) big wide healthy looking smiles even in patients with narrow arches. Patients with weak chins and poor profiles can see improvements often even early in treatment. In an ideal world every patient would naturally have developed big wide healthy arches with resultant large airways and enough room for their lower jaw to grow ideally.
One very special aspect of utilizing the DNA Appliance and Epigenetic Orthodontics is that the appliances are only worn for 14-16 hours per day. This is very different that standard orthodontics with brackets and wire or Invisalign®. Most of the wear can be done in your sleep, watching TV or commuting. During the day at work or with friends you can be free of the appliance. This is one of the special features patients love about the DNA Appliance, the convenient fit into your lifestyle.
The time when the appliances are out the teeth move to ideal position as nature and/or genes intended.
Typical orthodontics is a four-step process designed to move teeth through the bone. The first step is FORCE that creates PRESSURE (1) that compresses the periodontal ligament and puts pressure on the bone. The second step is INFLAMATION (2) which is associated with pain and discomfort. The third step which is RESORBTION (3) which is breaking down the bone by osteoclasts to create space. The fourth step is CONSOLIDATION (4) where new bone is formed. The process is then repeated after every orthodontic visit when braces are tightened or with each new Invisalign® tray.
Epigenetic Orthodontics is very different because it is a two step process. The forces are very light and movement is limited to 250 microns approximately every four days. The light forces are applied and growth and movement occur without inflammation which makes the entire process practically pain free. If there is any discomfort the adjustments are spaced out further.
Relapse is frequently a problem with orthodontics after orthodontists have used fixed braces to straighten crooked teeth. Relapse is the teeth moving back to their original position and relapse is why orthodontists make retainers. The reason for relapse is complex and not well understood. The hours when the appliance is out let the teeth follow natural eruption processes with far lower risks of relapse.
According to Dr. Dave Singh the Founder of the field of pneumopedics and craniofacial epigenetics which includes epigenetic orthodontics “there is a natural way for the body to remodel the upper airway, reshape bone and move teeth into their correct positions painlessly without the use of surgery, drugs or injections.”
Professor G. Dave Singh DDSc, PhD, BDS states on his website: “However, the entire human genome has now been sequenced, and we now know that certain genes are involved in moving teeth. Teeth are naturally-designed to move, for example, tooth eruption in a normally-growing child. In addition, the teeth in some people erupt in a specific arrangement, producing a beautiful smile. Dr Singh believes that the specific arrangement of teeth is due to certain genes. In fact, a natural process called ‘temporo-spatial patterning’ is at work. This process is the blueprint or body plan that is encoded by genes. In other words, the right and left sides of the body, the top and bottom of the body as well as the front and back of the entire body is under the control of a genetic body plan, including the teeth. Sometimes, however, the plan gets disturbed, producing crooked teeth and improper orthopedics.”:
Getting Older or Getting Better™. THE CHOICE IS YOURS! Come in and find out what is possible.
The Vivos DNA Appliance allows us to grow and develop a more ideal facial structure and a healthier airway.
Dr. Shapira has long had a special interest in developmental processes because of his work with sleep apnea in children and adults. Dr Shapira also has over 38 years experience in treating difficult TMJ Disorders, Migraines, headaches and other Chronic Pain. When these processes go are disturbed it changes how people breathe and swallow. Young children are frequently put in expanders to expand their maxilla or upper jaw. This is needed because of negative epigenetic changes caused by environmental allergies, food allergies or disturbed growth from insufficient breast feeding and bottle feeding.
Dr. Shapira, has taught classes to hundreds of dentists and their teams on how to treat sleep apnea with oral appliance therapy. It is one of Dr. Shapira’s students Dr .Martha Cortes who first introduced him to Dr Singh and to this exciting new field.
Dr Shapira has studied this field extensively and in 2014 gave a lecture in Buenos Aires, Argentina on the “Common Developmental Pathways of TMJ Disorders and Sleep Apnea.” These pathways are an example of negative environmental effects on development that can be reversed in adults who were not expanded as children. Prior to the DNA Appliance only extensive orthognathic surgery was available to widen or move bone.
Faces are different and each and every one of us is unique. Our appearance and physiology is determined by our DNA or genes. Genes determine our physiology and everything else about us. This is a description of Genetics
What many people are not aware of is that the environment and other factors can change how our genes express themselves. These types of changes are called Epigenetic changes.
Each person has a unique Genotype, these are the genes we inherited from our parents that when combined created a unique and special person. Identical twins actually share a identical DNA .
The Phenotype is how are Genes are expressed, the effects of the environment on us. These are the epigenetic changes that can be positive or negative in nature. This can be the difference between a big wide smile that shows all the teeth
What makes the DNA Appliance special is that it uses the patient’s own genes to modify and change not just the position of the teeth but the size, shape and position of the bone that holds the teeth as well as Pneumopedically change the size and shape of the airway. This 3-D spatial reconfiguring of the teeth and bone can make amazing changes not just in the teeth but in the face as well. The changes the DNA Appliance stimulates mimic the natural developmental process that occur in an ideal world. Biomimetic is the term used to describe what the DNA Appliance accomplishes, it mimics through biologic means what an ideal environment would have developed.
Oral appliances are frequently worn as a comfortable alternative to CPAP to manage snoring and obstructive sleep apnea. These appliances often protrude the lower jaw and are needed for life. Pneumopedics® is a term coined by Dr Singh to describe non-surgical upper airway remodeling is a different approach because instead of merely repositioning the lower jaw during sleep it gently allows allows the body to gently and gradually orthopedically increase the size of the upper jaw and increase the nasal airway. This has been shown in some clinical cases to create a cure for sleep apnea and snoring. The FDA-registered Daytime-Nighttime Appliance® system (or DNA appliance®) is worn during the evening and night for a total of 14-16 hours/day
Patients who are CPAP intolerant can utilize the FDA-cleared, patented mandibular Repositioning-Nighttime Appliance® (or mRNA appliance®) which works to maintain an open airway in the fashion of sleep apnea oral while gently re-developing the upper airway and moving the mandible or lower jaw and the teeth into a more natural position.
The DNA appliance® and mRNA appliance® protocols can effectively address TMD issues and headaches in both adults and children. Dr Shapira is a leader in the use of the DNA Appliance to finish phase two treatment in TMD patients.
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
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) .
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
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.
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.
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 [4, 5]. In addition, several studies [6–8] 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 [11, 12]. 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 .
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 [10, 12, 13]. 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 [10, 14], with the release of inflammatory mediators from blood vessels and activation of meningeal nociceptors, causing migraine pain [11, 14]. 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 [9, 10].
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 [10, 17–19].
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.
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
headache relief rate, defined as percentage of patients with 50% or more reduction in headache intensity at 15 minutes, 2 hours, and 24 hours;
change in NRS from baseline to 15 minutes, 2 hours, and 24 hours after treatment;
PGIC (effects on headache and its associated symptoms and tolerability) at 2 hours and 24 hours;
all adverse events up to 24 hours after procedure.
Statistical analysis was done using SPSS Statistics Version 23.
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.
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.
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).
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.
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.
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 .
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.
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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.
A beautiful esthetic smile must properly support the soft structures of the face, provide ideal airway and provide a state of physiological health.
Across the North Shore the are beautiful homes designed by top architects with great street appeal. Many of these homes are crumbling, have poor foundations, roofs and floors that sag and hidden potential problems that their owners don’t even suspect.
The best architects understand the important role of a structural engineer when creating beautiful structures. Beauty without stability is doomed to be short lived.
In Cosmetic Dentistry the structural engineering behind a smile makeover is based on principles of healthy physiology. The dental facelift is the result of applied physiology.
I have been deeply involved in esthetic dentistry for most of my 40 years of practice. I love creating beautiful healthy smiles but I always place physiologic health as the foundation for my cosmetic practice.
Treatment of Chronic head and neck pain, TMJ disorders, and autonomic and somatosensory dysfunction are the focus of my North Shore Highland Park office.
Personalized Precision Treatment is the key to successful treatment.
This office also treats patients with difficult problems that are outside the purview of most general dentists. Creation of physiologically healthy jaw relationships are the basis for the finest cosmetic reconstructions. Establishment of a healthy physiolgical condition can be life changing whether or not cosmetic dentistry is used to frost the cake.
In the 1990’s Dr Shapira was well known for his lectures on Anti-Aging Dentistry and Medicine. He was one of the first dentists in the world to practice dental sleep medicine and was the first dentist to be an Assistant Professor at Rush Medical School Sleep Disorder Center in 1985. He did research on jaw position and sleep apnea. He is the expert in offering alternatives to CPAP.
Many patients travel hundreds or thousands of miles seeking a better quality of life. Some are patients with headaches and migraines but others have far more complex issues like
Fibromyalgia or Ankylosing Spondylitis. If you have specific issues you can find patients with similar issues easily: https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos
While I do not do fillings, cleanings or routine dental exams in Highland Park I do perform major full mouth reconstruction and cosmetic cases in a environment of INDIVIDUAL PATIENT CARE, where you are the sole focus of the office. Many patients come strictly for treatment of difficult medical issues that normal medical treatment could not address. Others chose to also come to Gurnee for general dental care. I continue my general, implant and cosmetic dental practice in Gurnee. I founded Delany Dental Care Ltd in 1984 based on a passion for exceptional dentistry.
My partner Dr Mark Amidei is an artist and sculpto of beautiful smiles. Dr Richard Cottrell, my newest associate was the leading Lake Forest Dentist for decades and is a master at prosthetic and implant dentistry. He sold his practice in Lake Forest with every intention of continuing to practice there with the new owners. Unfortunately, Dr Cotrell found he could not contine to practice excellence in that environment and he is now practicing at Delany Dental Care. Over time, more and more of his old patients are discovering that they continue seeing the exceptional practitioned they have trusted for decades.…
The attached article (or a version of it) has been given as a research article at the Research Meeting of the SOT Chiropractic Research meeting, Presented to the American Equilibration Society, published by ICCMO and the AES.
It is widely considered one of the best explanations of physiologic dentistry.
Today, I think a far simpler explanation is also appropriate. Physiologic rest position is a area of homeostasis. Physiologic occlusion is a functional position that serve as a reset switch. Each and every time we occlude we then return to physiologic rest.
The lack of a physiologic bite means every time we occlude we enter a pathological state.
The purpose of a physiologic bite is to allow the body to heal and create a healthy postural chain.
Please read the original article but keep this simple description as what it all means
NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)
Ira L Shapira DDS, DABDSM, DAAPM, FICCMO
Physiologic 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 Physiologic 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 Physiologic 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 physiologic 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 physiologic 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 physiologic 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)
Physiologic 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 physiologic 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. Physiologic dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a physiologic reset switch during closure. Physiologic 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 physiologic bite is used to mount the
mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409
Physiologic 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.
Physiologic 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 physiologic and non-physiologic 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 physiologic 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. Physiologic 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 Physiologic 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 physiologic 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 physiologic evaluations of jaw relations with a Myotronic’s kinesiograph and a myomonitor to find physiologic 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
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.…