Transcript TMD/MIGRAINE THERAPIES SEMINAR

TMD/MIGRAINE THERAPIES SEMINAR
INTRODUCTION
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Approximately 37% of people in the USA have symptoms
of TMD
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Most of them are women. 15% of these people have
Migraines.
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In patients that have TMD, tension headaches and/or
Migraines, we are seeing more people in their mid 30’s
and older that are having these conditions. The lifetime of
a compromised stressed occlusion and muscle/joint
systems will accelerate the wear and tear of the teeth and
the temporomandibular joints.
Dr. Terry Tanaka in his book, TMD and Restorative Dentistry, A
Common Sense Approach 6th Edition
Dr.
Tanaka was truly a doctor ahead of his time
in understanding TMD and it’s treatment. He said:
“You can describe a TMD patient as simply a
fellow human in need of help. Anxiety is present
in varying degrees, depending upon the degree of
pain and/or degree of reinforcement by their
companions and friends. The patient may already
be envisioning the catastrophe of some type of
disease, or may even have a contributing
depressive condition”.
Dr. Terry Tanaka in his book, TMD and Restorative
Dentistry, A Common Sense Approach 6th Edition
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“Patients want to be listened to and understood. It sounds
simple, but only the very best of doctors ever fully attain
that goal in treating these patients. Patients expect
professional competence. They expect you to be a scholar
and knowledgeable about all the recent innovations in
your field of study. Patients want to be kept informed.
Patients want not to be abandoned. When there is no one
else to refer to, and the patient is on the verge of addiction
to pain medication, the caring role of the doctor becomes
larger than the curing role.
Dr. Terry Tanaka in his book, TMD and Restorative
Dentistry, A Common Sense Approach 6th Edition
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The multifaceted nature of these TMD pain disorders may
require multiple therapies from different disciplines, such
as physical therapy, behavioral therapy and splint therapy
to successfully resolve the pain”. (Dr. Tanaka made these
statements over 20 years ago)
(Dr. Terry Tanaka, TMD and Restorative Dentistry, A
Common Sense Approach 6th Edition. Clinical Professor,
Graduate Prosthodontics. Formerly Director, Facial Pain
Clinic University of Southern California School of
Dentistry).
The head and face are the focus of much human activity
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face is the main vehicle for communication, both
through words and facial expression, for perception, for
taking sustenance and air, for love and play. And as such,
it becomes the world’s window into our innermost being.
The head is crowded with complex structures reflecting
its many functions, while the neck contains many
delicate structures needed for support and precise
orienting of the head, as well as communication between
the brain and the body. It should not surprise us that this
complexity of function should be mirrored in a common
and highly varied series of complaints, some rooted in
organic disease, some rooted in the preoccupation of the
human mind, some rooted firmly in both.
The head and face are the focus of much human activity
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These complaints most commonly express themselves as
pain of the head, neck and temporomandibular joint, and
the intricacy of the underlying anatomy and psychology
demands an intelligent and cooperative approach from
many of the health sciences.
Charles McNeill DDS, Loma Linda Dental School, in his seminar:
“Demystifying TMD”
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Dr. McNeill said:“Old ideas and concepts about treating
TMD, head and neck pain and Migraines do not always
hold up. Old ideas can be difficult to change, even though
more knowledge has and is becoming available and more
specific management of joint symptoms and muscle
disorders are becoming better understood. Years ago
splints and adjusting the bite were all we were taught and
those ideas do not necessarily work for many patients,
because muscle and joint disorders that have been
developing over one or more decades in these patients can
become a large contributing factor in the diagnosis,
management and improvement in the patient’s progress”.
Neuromuscular Patterns
We
need to know and understand how
neuromuscular patterns affect these conditions and
their relationships to the head, neck, joints, loss of
range of motion, clenching and bruxing, and even
headaches, Migraines, occlusal wear patterns,
tinnitus, etc. We also need to know and understand
why these symptoms become more noticeable and
pronounced in the 4th and 5th decade of their lives.
Neuromuscular Patterns
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These questions come up. Does traumatic/stressed
occlusion contribute to these symptoms and problems or
do these symptoms and problems cause traumatic/stressed
occlusion? Which is a bigger factor? Also, does clenching
and grinding contribute to the cause of these symptoms
and problems or is it a result of these symptoms and
problems?
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Many factors may cause questions to arise in our
diagnosis. What contributing factors might we consider?
For example, we might have etiological factors, trauma,
hormonal, behavioral, overmedications, stress and anxiety
response, chemical (brain chemistry changes), bad habits,
poor diet, sleeping posture/patterns, poor body posture
positions during the day, etc.
We also need to consider the following:
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1. Lack of universally accepted criteria in our exam and
diagnosis.
2. Lack of knowledge regarding quite disparate TMD
symptoms.
3. Etiologic factors and their contribution to TMD and
headaches.
4. Occlusal factors. Are they a cause or an effect of TMD?
(The latest clinical data shows that many times occlusal
factors are a result of long standing muscular patterns that
result in clenching/grinding and in occlusal wear patterns that
ultimately increase the strain and stresses in the muscle joint
systems and neuromuscular patterns).
5. If there is an occlusal imbalance, when and how did it
develop and how might it be addressed?
We also need to consider the following:
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6. What sort of muscle and joint problems could be
involved and how could they be treated?
7. What might be the correct strategy and timing of
various treatment protocols?
8. When and should we use medications?
9. Are there alternative ways to treat patients without
medications?
10. When should we use a splint? How should we use a
splint?
11. When, why and how should we assess, address and
correct contributing occlusal factors?
12. What might be some accepted and often FDA
approved alternative therapy modalities that could be
used?
We also need to consider the following:
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13. Is clenching/bruxism a condition that can be
corrected….and if so, how can we accomplish that? How
does the clenching habit develop?
14. Is it possible to reestablish healthy muscle/joint/TMJ
and occlusal relationships and maintain them? If so, how
could that be accomplished?
15. Can overmedicated patients with brain chemistry
problems from Migraines and Migraine like headaches
(long standing tension headaches) be improved…..and if
so how?
We also need to consider the following:
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16. Are these patients typically chronic types? And if so,
what kind of maintenance program could be used after
their condition has improved?
17. Why do many patients with TMD have difficulty
moving comfortably into chewing excursions? Why are
some of these patients not even able to negotiate chewing
excursions?
18. Can we promote healthy excursion movements…and
if so, how?
Every one talks about TMD, but not many dentists treat it
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Dr. Christensen says that general dentists should be
treating these patients on a regular basis
(Dr. Christensen said in Dentistry Today Feb 2000)
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Since dentists see their patients regularly for their oral
maintenance visits, would it not make sense that the
dentist and hygienist would be sure to evaluate them for
any of these symptoms at least once a year.
Understanding the contribution that muscles and joints
contribute to TMD and headache conditions helps us to
realize the need for including them in a possible care
process.
(Dr. Christensen said in Dentistry Today Feb 2000)
Every one talks about TMD, but not many dentists treat it
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Because of the complex dynamic multifaceted nature and
relationship between head and neck posture, jaw position,
headache and head and neck related discomfort and
stressed dental occlusion, resulting in the ultimate
disturbance that may be seen in TMJ dysfunction, would
it not make sense to provide a multidisciplinary and
appropriate treatment protocol sequence.
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Abfraction, associated by many dentists and researchers
with occlusal stresses placed on teeth is well known. For
years, dentists thought the mysterious occurrence of deep
slots on the facial of teeth were caused by toothbrush
abrasion. Current concepts support the belief that these
may be caused by traumatic occlusal forces. We also see
these worn areas on other teeth as well. (Dr. Christensen
said in Dentistry Today Feb 2000)
What’s In A Bite?
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By Robert Supple DMD. Dr. Supple graduated from Tufts
Dental in 1980. He is a graduate of Pankey Institute and is
currently active in the American Equilibration Society and
the American Academy of Craniofacial Pain
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An unstable occlusion at 20 will tear up the joints in the
female by age 40. As the joints age the back teeth take
more force. Many patients have different dental materials
that wear at different rates and can be hard on an
occlusion. A dysfunctional relationship begins when any
anatomical structure ages at an accelerated rate as
compared to the individual’s ability to adapt, remodel or
repair the structure. Occlusal force that interferes with
either a braced centric closure or eccentric jaw
movements alters the lateral pole position of the condyles.
Some individuals will be able to physiologically adapt
over a lifetime, but most do not.
What’s In A Bite?
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The third decade of life uncovers the sometimes-subtle
periodontal changes of a stressed occlusion. There is a
strong relationship between the periodontal ligaments that
support the teeth and the posterior lateral ligament of the
T.M. meniscus. A stressed occlusion has the teeth and the
muscles trapped between the joint and teeth ligaments.
This is usually the decade of the popping jaw joints,
abfractions, periodontal pockets, cracked and/or broken
tooth syndrome and muscle tension headaches. If
ligaments fail to function or are stressed, stretched or torn,
then the muscle must adapt and help the ligaments hold
the jaw and teeth tight. Muscles cannot contract for long
periods of time without fatigue.
What’s In A Bite?
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Ligaments, muscles, teeth and periodontal health must all
work in harmony to prevent an occlusion from
prematurely aging. As the joint ages, the patient will lose
ability to hold centric in all functional positions. Even
though many people adapt and live with this condition for
years with no trouble, under excess stress it can, and
many times does lead to muscle triggers, ligament pain
and more pathology within the joint.
(Robert Supple DMD. Dr. Supple graduated from Tufts
Dental in 1980. He is a graduate of Pankey Institute and is
currently active in the American Equilibration Society and
the American Academy of Craniofacial Pain)
The million dollar question is
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“What process is doing the guiding?” The answer to this
question is the best-kept secret in dentistry because it can
change over time. The answer is: All the anatomy
together is the process responsible for a functional
occlusion. Dysfunction begins when form and function
are not in harmony and the anatomy must work against
itself”.
(Robert Supple DMD. Dr. Supple graduated from Tufts
Dental in 1980. He is a graduate of Pankey Institute and is
currently active in the American Equilibration Society and
the American Academy of Craniofacial Pain)
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The analogy that I like to use with our patients to describe
how the posterior teeth should fit together is similar to
closing a perfectly balanced door.
The million dollar question is
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When the mandible closes, the two healthy T.M. joints
(the hinges) rotate the lower posterior teeth (the door) to
stop and fit perfectly into the upper posterior teeth (the
frame). In this position, all the posterior teeth should stop
with equal simultaneous contact in one single plane. A
perfect true closure with up to 32 teeth coming into equal
stops at exactly one plane favors theory more than reality.
A lot of puzzle pieces have to fit perfectly in order for any
system to function clean every time. If a door closes
poorly, drags on the floor, or wedges into the frame
before closure, the system is in poor function. The door is
able to close but the space between the door and the
doorframe is not symmetrical. (Robert Supple DMD. Dr.
Supple graduated from Tufts Dental in 1980. He is a
graduate of Pankey Institute and is currently active in the
American Equilibration Society and the American
Academy of Craniofacial Pain)
The million dollar question is
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The question now becomes, “Is it the door, the hinges, the
door frame or all three that are out of alignment?”
Healthy condyles in a good braced centric position are
similar to tight door hinges. Pathologic T.M. joints
promote poor anterior guidance and eventually the door
and the doorframe continue to force each other out of
alignment. It is important that the first occlusal contact be
one of stability, occurring simultaneously on as many
teeth as possible. This can only happen when the teeth
surfaces are in harmony with the dictates of the correctly
seated condyles. (Robert Supple DMD. Dr. Supple
graduated from Tufts Dental in 1980. He is a graduate of
Pankey Institute and is currently active in the American
Equilibration Society and the American Academy of
Craniofacial Pain)
Dr. Peter Dawson explains in a similar way in his textbook,
“Evaluation, Diagnosis, and Treatment of Occlusal Problems”
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“The occlusal contours of all the posterior teeth are
dictated by both condylar guidance and anterior guidance.
No posterior tooth should interfere with either anterior
guidance or condylar guidance. Posterior teeth may either
be discluded from any lateral contact by the anterior teeth,
or they must be in perfect harmonious group function with
them and the condyles.”
Studies have shown
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That at age 18 the occlusal pattern is totally set and now
you can predict how an occlusion will age and which
teeth are taking all the force. Understanding how the
occlusion ages and the status of the current function is the
initial step to a successful and predictable treatment plan.
The occlusion ages as the patient develops unhealthy wear
patterns, such as chewing more on one side, and when
different restorations (amalgams, composites, porcelain,
gold, etc.) are gradually introduced into the patient’s
mouth. Each restoration wears differently and the
opposing teeth also wear differently. As the occlusion
becomes more and more unstable it creates dysfunctional
muscle positioning as the muscles try to adapt to the
occlusal changes.
Studies have shown
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Ultimately the TMJ condylar positioning becomes
compromised. In many cases, these patients may begin to
develop symptoms of TMD, such as headaches,
Migraines, tinnitus and other muscle and joint problems
of the head and neck.
What other components may be involved?
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For example: Airway anatomy, muscle anatomy, teeth
anatomy, condyle anatomy, periodontal anatomy and head
posture anatomy patterns all have an effect on the overall
function of the occlusion. The sensory input from the
teeth is directly related to the motor output of the cranium.
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Slides courtesy of Dr. Robert Supple “Digital
Occlusion/Habitual Patterns” research article
What other components may be involved?
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The anatomical components (1. Airway 2. Trapezius
Attachment 3. Occlusion & Periodontal 4. Lateral Pole
of Condyle) from growth set the framework for the force
distribution we see in digital occlusion. Asymmetric
anatomy at a young age will, over time, stress the
anatomical systems to adapt or fail by altering the
muscles, TM joints, teeth and foundation that supports the
teeth. (Robert Supple DMD. Dr. Supple graduated from
Tufts Dental in 1980. He is a graduate of Pankey Institute
and is currently active in the American Equilibration
Society and the American Academy of Craniofacial Pain)
What other components may be involved?
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Dr. Janet Travell, the master of muscle physiology and
trigger points, taught that T.M. disorders have a cervical
neck trigger. Poor posture pulls the mandible off center
and elevates Cranio pain disorders. (Posterior HFP’s
(Habitual Force Patterns**) all have elevated neck
triggers.) See Slide #30. Travell J. Simons D. Myofascial
pain and dysfunciton the trigger point manual. Lippincott
williams & wilkins. 1999 Volume 1: 279
What other components may be involved?
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**The HFP (Habitual Force Patterns) starts young and
the adult pattern is complete at about 15 years old. Some
additional growth may alter the force signature, but not by
much. Most 8 year olds have a straight center horizontal
pattern. By age 12, the child has picked a side, usually to
the side that the airway is limited. Digital signatures
(HFP) relate to the anatomy. For example: Airway
anatomy, muscle anatomy, teeth anatomy, condyle
anatomy, periodontal anatomy and head posture anatomy
patterns, all have an effect on the overall function of the
occlusion. The sensory input from the teeth is directly
related to the motor output of the cranium. Habitual
anatomical patterns, like wear facets, muscle pain,
abfractions or periodontal pockets, are diagnostic clues
for the dentist.
Tscan Digital Imaging
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Tscan Digital Imaging was used in 7a picture below.
See slide #32 and #50 for more Tscan details.
Slides courtesy of Dr. Robert Supple “Digital
Occlusion/Habitual Patterns” research article
The most common trigger in the human body, according
to Dr. Janet Travell (7b picture)
All force patterns that are located in the posterior quadrant
will have a trapezius trigger on that side! Excessive force
over time (functional and dysfunctional) cracks teeth as
demonstrated as in the next slides.
Tscan Digital Imaging
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The Trapezius trigger is diagnostic to a forward head
posture and the position of the cranium is directed by the
patterns like sleeping, eating, driving, working etc. The
trigger is easy to check in a dental chair because the
cranium is supported on a headrest. As the patient is
lying down the muscle attachment is in a perfect position
to palpate. All force patterns that are located in the
posterior quadrant will have a trapezius trigger on that
side! Excessive force over time (functional and
dysfunctional) cracks teeth as demonstrated below.
Tscan Digital Imaging Continued
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The HFP is heavy and wide left, altering the envelope of function.
Extra Force of ML #19 & DL #18 (Red Lines). Fractured
distal/lingual cusp on #19. The distal/lingual cusp will be the next
cusp to fracture.
Fractured
distal/lingual
cusp on #19, the
Distal Lingual
of # 18 will be
the next cusp to
fracture
Slides courtesy of Dr. Robert Supple “Digital Occlusion/Habitual Patterns”
Tscan Digital Imaging
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The most powerful diagnostic information about digital
occlusion is the ability to predict future stress on the
occlusion. The patterns are present a decade ahead of
most occlusion related disorders, like fractured teeth,
chronic muscle trigger and condyle ligament pathology.
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Facial and neck muscles, which undergo prolonged or
sustained contraction without adequate periods of rest,
can develop pain, fibrous adhesions and scar tissue within
the actual muscles themselves. The muscles can also
develop trigger point areas within the muscles themselves.
These trigger points can actually refer pain to other areas
in and around the Temporomandibular joint and the brain
as well.
Para functional habits
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Para functional habits such as clenching and bruxism have
been commonly implicated as part of the problem of a
TMD condition. Many times it is a neuromuscular
response to the occlusion becoming dysfunctional and
traumatic. Clenching and other parafunctional habits can
not only cause wear facets of the enamel/dentin, but also
put a load on the muscles and can adversely load the TM
joint, making the overall TMD condition worse.
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There also may be other contributing factors that can
initiate and even contribute to the symptoms. Common
contributing factors are whiplash, high stress levels and
anxiety, poor posture (as found in computer
programmers), poor sleeping positions and habits and so
on.
Dr. Peter Dawson said:
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Dr. Peter Dawson said: That when the anatomy is forced
to work against itself under function, over time, the
system must adapt. Ligaments, facets and abfractions
appear, muscles develop trigger points and the periodontal
system is stressed. (Functional Occlusion: From TMJ to
Smile Design by Peter Dawson, DDS 2006)
How important is occlusion?
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It is important that the first occlusal contact be one of
stability, occurring simultaneously on as many teeth as
possible. Squeezing the teeth after contact should not
produce any apparent sliding of the mandible in order to
affect a complete closure, and this can only happen when
the teeth surfaces are in harmony with the dictates of the
correctly seated condyles.
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Dr. Gordon says: “Many dentists are afraid of
occlusion….there is extreme controversy about what
concept of occlusion is correct, and I do not see any relief
to that controversy. Occlusion is a discipline that you
learn overtime and should never stop learning during your
entire career.”
(Dr. Gordon says in Dentistry Today, February 2004)
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How important is occlusion?
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Dr. Gordon also said in JADA, Vol. 132, January 2001
that dentistry today is involved with mostly three major
diseases or conditions: Dental caries, periodontal disease
and occlusal conditions. Dental caries and broken teeth
and periodontal disease are what most people associate
with dental care. He asks: Are there many people who
have occlusal disease or conditions? He answers: With
our aging population there are more challenges in
occlusion and TMD problems than used to be the case.
Excessive tooth grinding and clenching is the most
prevalent and destructive occlusal condition. Excessive
tooth grinding can eliminate canine and incisal guidance
in the dentition.
How important is occlusion?
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If conditions like these are not treated, not only do we see
excessive dentition wear, but increase of TMD symptoms,
broken restorations and teeth, and periodontal disease. On
a routine basis, almost every dentist inadvertently causes
occlusal trauma in these patients when placing
restorations in their teeth. In Dentistry Today 2000 Dr.
Gordon asks an interesting question: How does an
occlusion age? Or a better question is: Is your patient’s
occlusion aging at a faster rate than the patient’s age? (Dr.
Gordon says in JADA, Vol. 132, January 2001)
What is pain?
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Pain may be real or imagined. It is usually a warning that
something is wrong. It is important to understand that all
pain is real to the patient, even though the physical cause
may not be immediately evident to all examiners. When
your TMD patients hurt, they suffer, and when they suffer,
this suffering can be expressed through certain behaviors.
It becomes imperative that the clinician recognizes and
treats the cause of the pain, as well as recognizes the pain
behavior. In addition, the health professional must be able
to differentiate between the site of the pain and the source
of the pain.
In the case of pain disorders of the head and neck and
temporomandibular joint, most of the patients may have
been misdiagnosed by different types of professionals, and
therefore mistreated. The resolution of these pain disorders
may have been compounded and complicated by the longterm use of tranquilizers, antidepressant medications and
narcotics.
What is pain?
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Another major reason for the inadequate management of
these patients has been the improper application of the
knowledge that we have available. The reasons for this
include the lack of cohesive and organized teaching of
medical and dental students, physicians, dentists, and
other health professionals in the management of patients
with these disorders, and the progressive trend toward
specialization. This fragmented, specialized approach is
conducive to viewing pain problems in a very narrow
scope. Unfortunately, we tend to see only that which we
are trained to see.
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Acute pain disorders can be readily diagnosed and can
readily respond to treatment. When the pain becomes
chronic, however, psychological and neurological factors
begin to affect the pain response and the patient may
exhibit a pain behavior seemingly unrelated to the cause
of the pain.
What is pain?
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This pain behavior requires careful evaluation,
consideration and understanding to be successfully
managed. The unwillingness of some practitioners to
consider this psychological and neurological component
can lead to the incomplete resolution of the pain disorder.
It is therefore important to recognize and understand the
many components that make up the pain formula.
Importance of a comprehensive diagnosis
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A comprehensive and accurate diagnosis upon which a
definitive treatment plan formulated must be the basis for
the successful management of pain disorders.
In our office we have found that some of the most
common symptoms of TMD that patients may have are
ringing in the ears, also head, neck and shoulder pain,
tension headaches and/or Migraines. Rebound Headaches
are also getting very common, because the longer a
person stays on Headache and Migraine medications, the
worse the Headaches and Migraines become and the
stronger the medications needed, and eventually the
medications stop working as well. Most headaches are
caused by tenderness of the muscles and joints of the head
and neck and clenching and grinding, as well as referral
pain coming from the TMJ and from muscle trigger
zones. Migraines usually also have a dysfunctional brain
chemistry component.
Here is a list of information that we may need to know
1. A detailed analysis of their symptoms
2. How long has their problem been in development
3. Causative factors, such as whiplash, etc
4. Has their jaw ever locked out, how often has that
occurred and did they have to go to the hospital to have it
reset
5. Their age
6. Description of their headaches, and are they classic
Migraines or Migraine like (a long standing tension
headache can simulate a Migraine, but without the Aura)
7. What treatments they have had for their condition and
how successful they were
8. What types of doctors have they seen
9. A careful range of motion analysis of neck, shoulders
and oral movements, such as opening and closing and side
to side movements.
Here is a list of information that we may need to know
10. What sort of response do they have to stress
11. Have they had orthodontics
12. What medications are they on
13. Has a neurologist treated them
14. Which is more important, getting better or how much the
insurance will pay. (I really do not need to ask this
question, it almost always comes up)
15. Does the prospective patient try to control the
conversation
I do not make appointments with every patient. The
telephone interview, when done properly, will help me
determine which ones I really do not want to treat and
which ones that I can help. This brief interview actually
saves me a lot of time. I get very few broken
appointments, because I have already developed a
relationship with this person and gained their confidence.
Range of Motion Points of Interest
1. What does a range of motion analysis tell us?
2. Why is it important to do one?
3. How do we accomplish this exam?
4. How do we interpret the findings?
5. What are some of the causes of decreased range of
motion?
6. Why is it necessary to establish healthy range of motion
early in treatment?
7. What happens to a muscle to make it lose range of
motion?
8. How can decreased range of motion affect neuromuscular
pathways?
9. How can inflamed muscles affect and change
neuromuscular pathways and memory patterns?
10. How do these neuromuscular changes develop?
Range of Motion Points of Interest continued
In answer to some of these questions, we might mention
some preexisting nerve pathways that already exist in a
newborn at birth, such as the crying instinct, suckling,
uncoordinated hand and foot movements, crawling,
walking and language centers.
As the newborn gradually grows older, with good habits,
these pathways become highly developed, reinforced and
usually become healthy neuromuscular pathways with
increased range of activity. Also new pathways are
established, good or bad, depending on the development
of the child and habits that are introduced into their life.
Also, the preexisting pathways can change for the good
or bad.The good news is that neuromuscular pathways
have memory and damage to them can be corrected by
reestablishing healthy pathways in these areas.
Range of Motion Points of Interest continued
The question is: Can healthy neuromuscular pathways be
reestablished and if so how might that be accomplished?
First we need to understand why these pathways become
disturbed and what might become the end results.
To mention a few of the causes of changed or disturbed
neuromuscular changes, we might discover such things as
bad habits, sports injuries, stress, poor sleeping posture,
negative thinking patterns, whiplash, inflammation, scar
tissue, fibrous adhesions and toxicity in muscles, aging of
the occlusion, and muscle adaptive ability to these
changes, and possibly a clenching habit.
Decreased range of motion can commonly be seen as a
result of the above. The following slides suggest a few
possible methods of correction.
Range of Motion Points of Interest continued
To form a positive habit or change of a neuromuscular
nature, a “Habit Circuit” must be built in your brain. This
circuit will initially be weak, but can be strengthened by
the release of Dopamine, which is provided by a
“reward”(i.e, piece of food you like, after exercising).
With continual training (and dopamine release therein) the
Habit Circuit becomes so strong that it doesn’t require the
reward (e.g., the food reward is not needed).
A new positive habit circuit has now been created that is
self sustaining.
Another we can look at it is explained this way: A person
(patient) that has developed complex TMD symptoms,
headaches, clenching and occlusal wear patterns of such
a nature, that they require a comprehensive therapy
approach, has also developed destructive neuromuscular
pathways, that not only perpetuate the condition, but
continue to make it worse.
Range of Motion Points of Interest continued
These destructive pathways also can affect brain
chemistry activity in a negative way.
To repeat, “To form a positive habit or change of a
neuromuscular nature, a “Habit Circuit” must be built
in your brain”. The following slides 50-59 help to
understand how that might be accomplished and provide
some insight and ways that help to reset nerve pathways.
Therapy Equipment
I, and my staff therapist apply a comprehensive in office
treatment service, which may include the following: (not
necessarily in the order listed)
Ultrasound: FDA approved and clinically proven. As
muscles become stressed and inflamed, fibrous adhesions
and scar tissue form. The longer the muscles stay in this
condition, the more the potential for developing trigger
zones in these muscles. These trigger zones send referred
pain to other areas, including the brain. The Ultrasound
can gradually help to heal these areas.
Therapy Equipment
 Laser therapy: FDA approved and clinically proven.
According to many studies, the laser increases healing
potential between 25-35% over a 48 hour period after
each use. Because muscles have neuromuscular pathways,
it can also be used for resetting these neuromuscular
pathways and help speed up increase of range of motion.
By increasing range of motion, muscle healing can
progress sooner.
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Massage therapy: Trigger point and light pressure is used
until the patient can tolerate more. We do not get
aggressive, because we find that only makes the patient
worse.
Therapy Equipment Alpha Stim 100

Alpha-Stim 100 Therapy. FDA approved and clinically
proven and is one of the therapies we use for treatment of
head and neck muscle pain, trigger points, TMJ joint pain,
headaches and migraine headaches. Alpha-Stim
microcurrent delivers a safe dose of micro current that is
almost undetectable. These "micro-currents" attempt to
mimic the body's own natural electrical functions. "Patients
with treatment-resistant head and neck muscle pain, TMJ
joint pain, headaches and migraine headaches have shown
significant elevations in plasma serotonin."
Kulkarni, Arun D. and Smith, Ray B. The use of
microcurrent electrical therapy and cranial electrotherapy
stimulation in pain control. Clinical Practice of Alternative
Medicine. 2(2):99-102, 2001
Therapy Equipment: Alpha Stim 100
 University of Miami's School of Medicine quotes:
“Increases in cerebrospinal fluid level of beta-endorphins
up to 219%, plasma endorphins up to 98%, and
cerebrospinal fluid serotonin up to 200% have been
demonstrated in normal volunteers receiving 20 minutes
of Alpha Stim Therapy." All of these improvements in
head and neck muscle pain, TMJ joint pain, headaches,
migraine headaches and brain chemistry may be necessary
for treatment and relief from these conditions. (It is
painless and the pads treat the trigger zones)
Splint Therapy
Splint therapy: In our office we have found that, initially,
daytime use of the splint gradually helps the patient
discover when they are clenching. They are instructed to
keep a journal and note the times and how often they
clench. They are instructed to review the improvement
each week. They now can become consciously aware of
those times they clench and what triggers the clenching.
As the muscle and joint systems are now undergoing less
stress and are starting to heal and feel better, the clenching
impulse will usually be quieting down. Now, when they
are wearing the splint in the evening they will gradually,
at an unconscious level, decrease the intensity of the
clenching or even end the clenching habit cycle.
Therapy Equipment Tscan Digital Occlusion
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Occlusal Therapy: We use the Tscan digital computer
system for evaluating, adjusting and balancing occlusal
related interferences.
2D Moving Picture
3D Moving Picture
Tscan Use and Explanation
In the digital world, occlusion becomes a 3-D thinking
game that can be played like a digital movie. When you
add intensity, sequence, direction and patterns, the
colored marks have meaning in 100 planes of force, not
just one.
A dysfunctional relationship begins when any anatomical
structure ages at an accelerated rate as compared to the
individual’s ability to adapt, remodel or repair the
structure. Occlusal force that interferes with either a
braced centric closure (C.R.) or eccentric jaw movements
alters the lateral pole position of the condyles. Some
individuals will be able to physiologically adapt over a
lifetime, but most do not.
The sensory input from the teeth is directly related to the
motor output of the cranium. Habitual anatomical
patterns, like wear facets, muscle pain, abfractions or
periodontal pockets, are diagnostic clues for the dentist.
Tscan Use and Explanation Continued
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In most occlusions, at least one of the condyles translates
in front of the other and we define our envelope of
function in the third dimension, (3-D). Each pattern gives
an insight to understanding how a bite will age, which
teeth are doing the guiding and how the bite force is
absorbed and released on the occlusion. Knowing the
intensity, sequence, and direction of all the occlusal
contacts can advance your diagnostic and treatment skills.

The T-scan software allows the practitioner to record,
store and quantifies the pattern and direction of force that
the mandibular teeth and/or prosthetics place on the upper
occlusal plane. The computerized articulating paper
places a value to every tooth contact in both two and three
dimensions.
Tscan Use and Explanation Continued
 As the patient taps from initial force, to maximum force,
to releasing force, they develop a repeatable signature
force pattern. In a five second movie, the software will
record hundreds of planes of force.
 Each tap records a similar force sequence. As the patient
taps a second and a third time, they have a tendency to
load the joints a little better with each tap.
 The summary of all the taps is a pattern that defines the
force distribution of the patient’s occlusion.
 The squeeze at the end of the recording is the force on the
occlusion when the patient is in habitual interlock. (It is
also referred as MIP, Maximum Intercuspal Position.)
 Keep in mind that the HFP is a movie recording of how
force is transferred throughout the occlusal cycle. The
diagnostic patterns show direction, sequence, intensity
and repetition of force. Some patterns dominate the front
teeth and others are located on the back teeth.
Home Training Manual
We always tell our patients that TMD is a complex
condition and requires regular maintenance. Since most
of these conditions are of a chronic nature, our office
trains each patient on home management of their
condition. They get a training manual so they can
manage their condition better.
We tell them the following and emphasize the
instructions at the training visit and at each visit.
1.TMD (Temporomandibular Joint Dysfunction) is a
complex condition involving the muscles and joints of
the head, jaw and neck. It is chronic in nature. It also
includes the upper and lower jaw and their proper
relationship to one another. Being of a chronic nature,
regular maintenance is necessary.
2. For the best results ‘carefully read and follow’ these
instructions.
Home Training Manual
We train them on the following:
How to use ice and heat and neck for stretching to increase
neck range of motion, which is critical in these patients.
Exercise to increase oral opening and closing range of
motion.
How to use home microcurrent to help heal the muscles
Healthy sleeping recommendations
Stress management
Awareness techniques
Deep Breathing and Relaxation exercises
Five step strategy for anxiety control
Things that are harmful to their muscle health
We always tell our patients the following:

TMD (Temporomandibular Joint Dysfunction) is a
complex condition involving the muscles and joints of the
head, jaw and neck. It is chronic in nature. It also includes
the upper and lower jaw and their proper relationship to
one another.

That is why we have done such an extensive history and
evaluation. The best therapeutic improvement is a result
of good patient and clinician communication and mutual
cooperation in the treatment. We anticipate that you will
begin to see improvement in your discomfort in four to
six weeks. However, due to the chronic and complex
nature of TMD, it could take a longer period of time.
Research Articles

Dr. Robert Kerstein, a pioneer in occlusal therapy, has
been teaching dentists for 20 years about the relationship
between occlusal force and muscle function and how this
affects neuromuscular pathways. He wrote a paper that
dealt with how the Tscan digital occlusion system, when
occlusion is in function and how the muscles contract and
release using the Biopak Electromiography recording
System by Bio Research. These two integrated diagnostic
systems, illustrates how the occlusal patterns directly
affects muscle activity levels. Functional adaptation of the
TMJ muscles, posture and the foundation that supports the
teeth, can be physiologic, pathologic or both over the life
of a person’s occlusion and muscle joint systems. Dr
Robert Kernstein Cranio, April 2004, “Combined
Technologies: A Computerized Analysis System
Synchronized with a Computerized Electromyographic
System.
Research Articles

Surface EMG recordings were taken on 43 subjects with
pain in the craniomandibular muscles and 17 controls.
The results show that the subjects with muscle pain use
their anterior temporalis muscles with less frequency and
with less intensity in several responses than normal
subjects. Bilateral activity demonstrates that subjects with
muscle pain have a more severe asymmetrical recruitment
of these muscles than the more symmetrical recruitment
seen in normal subjects. Muscle pain clearly altered the
recruitment of their jaw muscles, supporting the concept
that the neuromuscular system is altered in patients with
craniomandibular disorders. Nielsen, I.L., McNeill, C.,
Danzig, W., Goldman, S., Levy, J., and Miller, A.J.:
Adaptation of Craniofacial Muscles in Subjects with
Craniomandibular Disorders. Am J Orthod Dentofac
Orthop, January 1990, p.20-34.
Research Articles

Resting EMG levels were obtained from masseter and
temporalis in asymptomatic, subclinical, and patient
groups. Patient group demonstrated significantly higher
EMG activity than the asymptomatic or subclinical
groups. Temporalis was found to be a site of greatest
EMG activity more frequently than the masseter. These
findings strengthen diagnostic and assessment procedures
and criteria. EMG resting levels were determined for
patients and controls for frontalis, temporalis, and
masseter muscles. For each muscle, EMG activity was
significantly higher for the MPD group than for controls.
Research Articles
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Subjects with muscle pain and tenderness demonstrate
five neuromuscular characteristics of the jaw closing
muscles as determined by EMG studies with 1) increased
postural activity of the jaw closing muscles; 2) less
electromyographic activity during maximal contraction
such as during clenching; 3) increased duration of
masticatory discharge; 4) increased masseter muscle
activity during night bruxism; and 5) spastic discharge of
the ipsolateral temporalis muscles when a subject attempts
to move the jaw over the disk without reduction. Miller,
A.J., Nielsen, I.L.: Neuromuscular Compensation in
Subjects with Craniomandibular Disorders. EMG of Jaw
Reflexes in Man, 1989, Leuven University Press.
Research Articles
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Over forty dental schools world-wide have produced over
120 studies...all validating two central facts about muscle
activity: Patients with craniomandibular dysfunction have
distinctly different patterns of muscle activity (at rest, in
clenching, while chewing, and while speaking) than the
asymptomatic "normal" subject. So EMG clearly confirms
and quantifies the presence and severity of this muscle
dysfunction. Successful treatment reduces the irregularity
and severity of muscle dysfunction. So comparison of
post-treatment muscle activity with pre-treatment baseline
documents treatment efficacy. Gervais, R., Fitzsimmons
G.W., Thomas, N.R.: Masseter and Temporalis
Electromyographic Activity in Asymptomatic,
Subclinical, and Temporomandibular Joint Dysfunction
Patients. Journal of Craniomandibular Practice 1989;7:5257.
Biomechanical Relationship Between Head, Neck and Teeth
Inevitably there will be a biomechanical relationship
between forces developed in dynamic stabilization of the
heavy cranium, tension on the deep cervical fascia,
stabilization of the cervical vertebral segments,
movements of the T.M. joints, activity of the hyoid bone
musculature as well as the structures of the shoulder
girdle and thoracic outlet. Moreover, there is a clinical
relationship between postural/occupational stress,
tightness of muscle or other soft tissues connecting these
bony structures, malocclusion of teeth, and joint
dysfunction with, neck pain, headache, orofacial pain,
abnormalities of chewing and swallowing and the various
myofascial pain and dysfunction syndromes about the
head, neck and shoulders. Basically then, the skull is
directly associated with two of the body's most
complicated joint systems (the TMJ and atlanto-occipital
articulation) and one of the body's least understood and
most controversial joint system (the cranial sutures).
Biomechanical Relationship Between Head, Neck and Teeth
Continued
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When it comes to the phenomena of head pain there is an
unequivocal logic in viewing the joint systems of the skull
as highly integrated structures whose functions are
inseparably related.
The temporomandibular joint (TMJ) is the most active
joint of the body, moving up to 2000 times each day. It
functions in mastication, swallowing, respiration and
speech. Additionally, it directs postural relationships of
the head, neck, and tongue, hyoid and mandible.
The posterior joint system is composed of the atlantooccipital articulation, suboccipital and intrinsic muscles,
ligaments, vertebral artery, and nerves. The atlanto-occipital articulation is a freely movable diarthrodial
articulation of the condyloid type. This functional unit as
well as the atlanto-axial are unique in the spine as they
have no intervertebral disc.
Biomechanical Relationship Between Head, Neck and Teeth
Continued
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The head 1itera1ly teeters on top of the cervica1 spine
with a center of gravity anterior to the spine. It is tethered
to the body by the muscles of the anterior and posterior
joint systems. Functional and resting head posture is
dependent upon tension in these muscles. It follows then
that mandibular movement and head movement must be
intimately associated.

Movement of the mandible is not limited to the muscles
of mastication, but will also cause reflex muscle
contraction and compensatory stabilizing activity of the
posterior cervical muscles, and the musculature of the
entire anterior joint system.
Biomechanical Relationship Between Head, Neck and Teeth
Continued
 Cervical spine posture, head posture, and mandibular rest
position are all intimately related and a change in one
necessarily affects the others. This becomes clinically
obvious in examining the body as it attempts to preserve
the relationship of the horizontal planes of the skull to the
vertical axis of the spine, while maintaining a patent
airway and mandibular orthofunction.

There is a dynamic relationship between head posture,
mandibular postural rest position (MPRP), and dental
occlusion. When the head and neck are held in lateral
flexion, the occlusion contact becomes stronger on the
side to which the head is bent .

Occlusion requires a pattern of muscle activity to bring
the mandible from a resting position into the intercuspal
position (ICP).
Biomechanical Relationship Between Head, Neck and Teeth
Continued
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Ideally, the teeth should meet simultaneously in
maximum ICP during closure. The wide distribution of
afferent impulses to the CNS results in a balanced
neuromuscular response that is within normal
physiological demand and results in a relative relaxation
of the mandibular musculature.
When the teeth, or part of a tooth, meet prior to ICP, this
is termed malocclusion. This uncoordinated bite results in
a dramatically different afferent impulse scheme. The
aberrant stimulation of periodontal receptors causes overrecruitment of masticatory muscles to compensate and
reposition the mandible as the ICP approaches. The
neuromusculature system must adapt by changing the arc
of closure at the expense of additional muscle activity.
The objective of treatment would be relief of symptoms
and orthopedic repositioning of the head, neck, and jaw to
a neuromuscularly balanced position.
Possible Therapy Protocols
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We do four things and we do them in a specific order.
Muscles get inflamed and build scar tissue and fibrous
adhesions. The muscles develop trigger zones and
toxicity. Toxicity in the muscles gets stored in the muscle
in the area called the trigger zone. These toxins send
negative signals to other parts of the upper body and
brain. They can also affect brain chemistry.
So we do the Ultrasound first because it produces heat,
which relaxes the muscles, and it also produces sound
waves that penetrate the deeper muscles to break up any
scar tissues and adhesions found in the muscle. The
Ultrasound also helps release these toxins as well. Then,
we do massage therapy, which will relax the trigger zones
even more, and this helps slows down the negative
signals. During the massage we only do pressure point
massage. We never get too aggressive because it can
make the patient worse.
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Possible Therapy Protocols By Our Therapist
Next, we use the Alpha-Stim which is like Acupuncture
but without the needles. It further treats the trigger zones
and decreases the negative signals. While using the
Alpha-Stim the patient rates how painful their trigger
zones are on a scale from 1to10. Around the 4th or 6th
visit, the patient will usually tell us the trigger zones are
under a 5. This is usually when they begin feeling better.
Lastly, we use a cold laser, which resets neuromuscular
pathways and increases range of motion sooner. The laser
also sets of an increase in healing potential of 25-35%
over the next 48 hours. The faster we get a patient’s range
of motion improved, the faster we get the patient feeling
better. To help you understand better, let me illustrate it
for you. Say you sprain your elbow and it’s put in a cast
for 3 months. Once it’s taken off do you think you can
straighten your arm? Of course not. Why? Because the
muscles have atrophied and have lost neuromuscular
signals to the arm due to lack of use.
Ultrasound Therapy By Our Therapist
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Ultrasound is an instrument that produces sound waves
that penetrate the deeper muscles so they relax and are
more pliable for the massage. I apply gel to the jaw, neck,
and shoulders and then use the probe in a circular motion
on those three areas. Apply the ultrasound gel and put a
little on top of the probe. We do 4 minutes on each side,
and after each side, I give the patient a towel to use to
wipe the gel off. During the Ultrasound use, it’s often best
to make the patient feel comfortable, so tell them to please
sit back and relax, and always ask if they are comfortable.
Make sure they are not leaning forward during the
treatment, whereas that would mean they are engaging
their muscles and therefore will not receive the full
benefit of the Ultrasound.
Ultrasound Therapy By Our Therapist

Also, during the treatment we ask questions that aren’t too
personal so that we can get to know each other. Such as:
Which side is most tender? Where do you feel that your
headaches are coming from? Have you ever had a
massage? Are you right or left handed? These questions
will allow you to become even more familiar with the
patient and will allow you to be able to focus on the areas
they showed you that are bothering them.
Massage Therapy By Our Therapist
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Next we do massage. I will rub the masseter, occipitals,
neck, and top of the shoulders and focus on trigger points.
Start off by lightly rubbing the lotion on the jaw and neck
so that the lotion can start relaxing the muscles. Then start
with one side of the Jaw. In a circular motion, use your
index and middle finger to rub right under the cheekbone,
always starting with light pressure. As I am massaging, I
ask them on a scale from 1 to 10, 10 being very painful. If
there are any spots that are a 5 or above, remember those,
as we will focus on them with the Alpha-Stim. Always
ask how the massage pressure is feeling.
Then from behind the patient, use your fingers and slide
under the cheekbone. Apply a little pressure as you are
sliding slowly down the cheek and have them take in deep
breaths, which helps relax the muscle. Then go to the
temple and massage the same as you did for the masseter
massage.
Massage Therapy Continued
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Then move to the occipital ridge and apply some lotion
and then choose a side to start with. Then using the tip of
the index finger, go to where the spine starts and apply
pressure (checking as you go) right under the ridge. Stay
in one spot and have them take a deep breath. If the spot
is especially tight stay a little longer and have them take 2
to 3 deep breaths. Continue this process until you are near
the ear. Then do the other side starting again at the spine.
Then rub down the scalenes and the sternocleidomastoid
(SEM) using the same circular motion. Once you are at
the end of the SEM, using the tip of your index finger,
stroke along the clavicle.
Apply more lotion to the top of the shoulders and then
start rubbing them. Usually you’ll find some knots in the
muscle and you can try to apply more pressure, as you try
to work the knots out.
Alpha-Stim Therapy By Our Therapist

Next we’ll do the Alpha-Stim therapy, which is a
sophisticated micro-current that is put directly on the
trigger points. During the massage we found the spots in
the muscles that were a 5 and above. Before you start with
the Alpha-Stim, confirm those spots on each side that
were the most tender and then we explain how the Alpha
Stim works and how it is used. The Alpha-Stim is a
Micro-Current and focuses on the “hot spots” in muscles
by going directly to the nerve to release the muscle. Tell
them that once it’s on they’ll feel like an itch or pinch that
is not uncomfortable, but you don’t want to go any higher
once they feel that. Teach them about the number three
setting and scrolling up in number until they feel it. If not
scroll back down and go to the 2nd setting and try again.
Alpha-Stim Therapy Continued

Most TMD patients that have had these symptoms for a
long time will usually not feel anything from the AlphaStim, especially if you use it on their neck. So make sure
you tell all your patients that some don’t feel it and that’s
fine, but it’s still working, so they shouldn’t worry. Once
you have explained everything to them, then have the
patient feel the spot you are going to treat, and let them
confirm the pain number again and then put the Stim right
on the spot.
Alpha Stim Therapy Continued
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The unit will beep every 10 seconds and then you move
the probe around the spot in a little circle. Then the patient
feels the spot and tells you if it’s come down in number.
General goal: If it starts at a 7/8 usually try to get it down
to a 5/6. This might take a few treatments per area. If it
starts at a 5 then try to get it down to a 3/4. Again with
patients who have been dealing with this condition for a
long time it might only go down one number on their first
treatment, but that’s ok, because it’s still working and it
will just take more visits to improve. After you are done,
make sure you ask them how they are feeling and if they
liked everything. Remember to tell them to drink LOTS
of water after every treatment. Then write in the charts all
3 steps and where you used the Alpha-Stim, and the
numbers they were before and after.
Laser Therapy
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Then we use a cold laser that works by stimulating the
muscles to increase energy and fuel to the muscle, thereby
allowing the muscle to relax and heal at a 25-35% faster
rate over the next 48 hours. The laser also sends a signal
to the brain reconnecting neurological feed back loops
that inhibit PAIN. The long and short is that the laser
works on non-heat, bio stimulation to help all areas of the
body to heal 25-35% faster than normal.
**Reminder: After each appointment, always make sure
you ask them how their home care program is going?
Remember to tell them how crucial this is to the treatment
program and always encourage them to stay regular with
it.
When it is the patient’s last appointment, make sure to
schedule an hour for them so you can reevaluate the
muscles.
Therapy Reminders

Regularly check the charts from the Patient Exam
Forms so as to know specifically how the Dr. rated the
muscle pain and if there are any trigger points (hot spots
in the muscle that are very tender). Examples of where
Trigger points might occur are occipital ridge, masseters
and even the neck, shoulders and temple.
Conclusion:

Therefore, the objective of a successful treatment program
should be to gently and naturally bring the head, neck,
jaw and occlusion into a neuromuscular balanced
alignment. Functional and resting head posture is
dependent upon the proper tension in the muscles and
joints involved. In other words, the head literally teeters
on top of the cervical spine. It is tethered to the body by
the muscles of the joint systems. The functional and
resting head posture is dependant upon the proper tension
in these muscles. It follows then that the jaw movements
must be intimately associated. Movement of the jaw is not
only related to the muscles of mastication and to chewing,
but also to chewing patterns and head and neck posture.
Head posture, neck posture and jaw relationships are
intimately related and a change in one necessarily affects
the other.
Conclusion:

Because of this dynamic relationship between head and
neck posture, jaw position and dental occlusion and its
ultimate disturbance that is seen in TMJ dysfunction,
headache and head and neck related discomfort, it
becomes necessary to provide an appropriate and
comprehensive treatment protocol for optimum results.

I quote Terry Tanaka: “The multifaceted nature of these
TMD pain disorders requires multiple therapies from
different disciplines to successfully resolve the pain”.