Severe Bruxism/ Neuromuscular Dentistry/ Dental Sleep Medicine/ TrigeminoCardiac Reflex and SPG Blocks are all connected and part of the same system

Dr. Shapira TMJ 0 Comments

What is the common underlying link of all of these.  The Trigeminal Nerve and the Autonomic nerves of thee Sphenopalatine Ganglion.
Self-Administered SPG Blocks can improve many autonomic issues in patients.
This is the connection of TMJ disorders to problems with the gut.
The connection of Aiirway collapse secondary to dental issues has been well established.
Bruxism is far more than a habit it is part of a medical group of disordrs.
. 2018 Aug; 4(8): 329–331.
Published online 2018 May 18. doi:  [10.1016/j.hrcr.2017.06.013]
PMCID: PMC6092563
PMID: 30112280

Grinding to a halt: Stimulation of the trigeminal cardiac reflex from severe bruxism

Key Teaching Points

  • • The autonomic nervous system has an intricate relationship with the heart; severe vagal stimulation can produce bradycardia and asystole.
  • • The trigeminal cardiac reflex is a powerful brain stem reflex that can be associated with a sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, or gastric hypermotility.
  • • Bruxism, which is reported in 8% of the population, can stimulate the trigeminal cardiac reflex and lead to profound vagal effects on the heart.

Introduction

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% and has been explicitly linked to the TCR.We 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.

Case report

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.

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Holter monitoring revealed sinus bradycardia, intermittent second-degree type II atrioventricular block, and a pause of 8.6 seconds

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Illustration of the trigeminal cardiac reflex. X = motor nucleus of the vagus nerve; ∗ = Gasserian ganglion; V = trigeminal nerve.

Discussion

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.

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. 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. 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.

Conclusion

When evaluating patients who present with symptoms of significant hypervagotonia, it is important to consider sleep-related causes, in particular sleep bruxism and its role in the TCR.

Footnotes

Dr DeSimone is supported by an NIH T32 training grant (HL 007111).

References

1. Reding G.R., Rubright W.C., Zimmerman S.O. Incidence of bruxism. J Dent Res. 1966;45:1198–1204. [PubMed]
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]

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

Dr. Shapira Blog, TMJ 0 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 …

The Sphenopalatine Ganglion Block for Relief of Facial Pain from the Nasal Mucosa.

Dr. Shapira Chicago, Highland Park, TMJ, Uncategorized 0 Comments

This new article in Cranio (abstract below) discusses use of SPG Blocks in treating Facial Pain of Nasal Origin. I teach patients to self administer these block for many types of headache and facial pain.

This specific case was due to a nasal contact headache where the nasal turbinate is touching the septum.

Another approach is to grow the underdeveloped maxilla to open up airway, decrease sinus pain and infections while improving breathing.

This video is a patient who has used SPG Blocks in the past but is now making permanent changes in her nasal airway to improve health including TMJ disorder with the DNA Appliance and Epigenetic orthopedics/ orthodontics.

Cranio. 2018 Jun 8:1-3. doi: 10.1080/08869634.2018.1475859. [Epub ahead of print] Efficacy of sphenopalatine ganglion block in nasal mucosal headache presenting as facial pain.
Lee SH1, Kim Y1, Lim TY1.
Author information
Abstract
Background When intranasal contact points are the cause of headache and facial pain, opinions regarding whether to remove intranasal contact points when they are believed to be the cause of headache and facial pain are divided. Clinical Presentation A 46-year-old woman visited the authors’ pain clinic with complaints of right nasal pain accompanied by frontotemporal headache. She first met an Otorhinolaryngologist and a neurologist. Based on nasal endoscopy and pain pattern, they presumed that her pain was a nasal mucosal headache rather than migraine. A mild septal deviation to the right side with bony spur near the inferior turbinate was observed. The use of medication provided very insufficient relief. However, the sphenopalatine ganglion (SPG) block provided excellent pain relief, and the effect lasted for six months. Conclusion Considering the mechanism of pain in intranasal contact point headache, (SPG) block is a potentially effective therapeutic tool.

KEYWORDS:
Sphenopalatine ganglion block; facial pain; nasal mucosal headache; trigeminal afferent nerves…

TMJ Chicago

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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TMJ Treatment: Across Illinois, Wisconsin and the Midwest

Dr. Shapira Blog 4 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anti-Aging Dentistry and Cosmetic Reconstruction

Dr. Shapira Chicago, Crowns & Bridges, Deerfield, Dental Veneers, Epigenetic orthodontics, Evanston, Highland Park, Jaw Pain Clicking & Popping, Jaw Problems, Mettawa, Northbrook, Uncategorized 0 Comments

Can dentistry provide a virtual fountain of youth? Beautiful smiles are about far more than white teeth. Beautiful Smiles ideally have healthy anatomical and physiological basis.

Face lift Dentistry, Virtual facelifts, Denture Facelift are actually possible by utilizing physiologic dentistry and esthetic dentistry to recreate an ideal physiological position for the maxilla and mandible.

This may seem impossible but is more understandable when you consider TV shows like CSI.

The skeleton and the teeth supports the soft tissues of the face. In theses shows the do dramatic recreations of the face from just a skull. They know based on bony landmarks what the soft tissues will look like. Changing the bite in these patients would drastically change the entire facial reconstruction. The power of ideal dentistry is immense.

Bringing the lower jaw forward give a stronger chin bringing it back gives a weaker chin. The bite, the way the teeth create the length of the face is described in dentistry as vertical dimension. Increasing vertical dimension give a longer less round or chubby face with more prominent cheekbones.

Decreasing vertical dimension makes the lips narrpwer and causes the corners of the mouth to droop. Decreased vertical dimension is also associated with forward head posture and neckk and back pain.

The position and size of teeth give support to the cheeks and lips.

Denture patients can have “plumpers added to their existing dentures for a younger healthier look even when the actual teeth are ideal.

The use of the DNA Appliance can orthopedically grow the maxilla and mandible larger actually restoring natural genetic potential.

Due to environmental pollution, soft diet, allergies and insufficient breast feeding most Americans have underdeveloped jaws compared to historical anthropological norms.

This underdeveloped gives narrow arches and narrow unattractive smiles with dark buccal corridors. It is responsibe for crowding and other cosmetic issues. The DNA Appliance is the best non-surgical approach to correcting these problems in adults.

Adults were all once children and the best time to correct the problem is at two to seven years of age with orthopedic growth unfortunately the majority of orthodontic patients start too late to correct these problems easily.

These same developmental issues are associated with snoring, sleep apnea, chronic pain, headaches, migraines an TMJ disorders. Problems like ADD, ADHD, Dyslexia, OBD are also associated with this underdevelopment.

Early intervention can prevent many of these problems, especially ADD, ADHD and behavioral disorders. Early intervention is between 2 and 7 years old. The faces of kids with problems show signs even before 2 years of age. Sometimes referred to as adenoid facies or just FLK (funny looking kids).

The single most important thing are jaws and teeth do is maintain our airway when awake and asleep.…

Why Patients Are Forced To Live With Severe Pain and Migraines

Dr. Shapira Uncategorized 0 Comments

It is an unfortunate truth that headaches that are often easy to treat end up damaging patients quality of life for many years, often wrecking their entire lives.

I recently saw a patient who kept diaries in second grade and talked about her headaches every day. She has had constant pain for the last nine years.

We started treatment with a diagnostic physiologic orthotic and trigger point injections in her trapezius muscles and for the first time in nine years she was out of pain.

She had spent a week at Mayo Clinic where she was told she had migraines and to “get over it, its genetic” and told to just accept it.

Nothing like taking away a patients hope.

She has had an orthotic now for 24 hours anThis patient has a problem with pain from muscles but no particular problem with clicking or popping joints.d is astonished she is still pain free.

The Trigeminal Nerve is the center of all headaches and as everyone knows the Trigeminal Nerve is the Dentist’s nerve.…

Dentist Chicago | TMJ Chicago



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A scientific approach,
with a personal connection


ira2Dr. Ira Shapira: “I love science. Science provides the necessary facts, to better understand people’s issues as a healthcare provider. Applying these facts properly (recognizing that every individual deserves personalized focus, attention and treatment), is the key to Effective TMJ and Sleep Disorder Solutions.”


What is a TMJ disorder?

Everyone experiences the occasional headache, shoulder pain, or sore neck. Most of the time we can dismiss the cause as nothing more than stress or our busy lives, but, when pain becomes a daily occurrence or is accompanied by other symptoms, there could be something more going on.

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What is a sleep disorder?

If you find yourself constantly battling fatigue, feeling as if your sleep is disrupted on a nightly basis, or if your family complaints about your snoring, you could have an underlying sleep disorder. There are several, common sleep issues (e.g.: sleep apnea) that plague many individuals like you.

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Why Dr. Ira Shapira?

“I like to think of my patients as though they were members of my family. I want them to have the quality of care they can appreciate and that I would expect for myself or my family. That’s why I try to stay current with the latest findings in the field of Physiologic (TMJ) and Sleep Disorder dentistry.

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    It’s time to get rid of those headaches once and for all. Set up a consultation with us to discuss the connection between your chronic headaches and a potential TMJ disorder.

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