1. Bringing Oral Habits Under Control in Your Office Today:
Advances in the Management of Oral Habits and Mouth Breathing: Part I
InnerSmilePro
RESPIRATION
AND
ORAL HABITS
AWARENESS TRAINING
Carl Gugino, D.D.S., M.S.
Robert Grove, Ph.D.
Bringing Oral Habits Under Control in Your Office Today:
A Realistic Model for the Average Practitioner Using Existing Staff
Version

2. DISCLOSURES AND PROPERTY RIGHTS
Drs. Gugino and Grove want you to know that they are co-owners in the products on which this presentation is based. They also own the intellectual property.
The material presented here is based on the intellectual property of the presenters. The final product is based on 27 years of development.
ACKNOWLEDGEMENTS
We could never do this by ourselves. We wish to thank hundreds of colleagues for their help over the years. Special thanks to Dr. Ivan Duc of Italy, Dr. Carl.F.Gugino’s Florida Study Group, The Bioprogressive Society of Japan, including Dr.Hiroshi Nezu, Dr. Kenji Nagata, Dr.Katsura Imai, Dr.Osamu Watanabe, Dr.Makoto Nakao, and Dr. Dr. Joseph Caruso, and Dr. James Farrage of Loma Linda Dental School, California, for their leadership.

3. Loma Linda Mafia

4. The Three Musketeers

5. Carl Gugino
Worked with Ricketts. Developed multi-modality office management.
Brought Breathing, Exercise, and Psychophysiology to Case Management.
Master Teacher of ‘ZeroBase’ – case management by level of difficulty.
Started sEMG in 1970s with the Cram Scan.
International Mentor – Europe, South America, Japan.
Brought together Grove and Duc in Italy to form SEMG team.
CoOwner, InnerSmilePro.

6. Ivan Dus
Works with Gugino in Europe. Extensive knowledge of physiology. MD.
Set up ‘ZeroBase’ computer team – case management by level of difficulty.
Brought together Grove to Italy to develop sEMG team.
Got degree in neurophysiology and behavior.

7. Bob Grove Medical Psychologist @ neuropsychophysiology, biofeedback.
Primate surgery lab. Full physiology research laboratories.
Founded Neuronal Regulation Society.
Three times President, Biofeedback Society of California.
Rheumatology research. Soft-tissue evaluations.
Hundreds of sEMG CMD evaluations.
The missing link – psychophysiology in severe dental-ortho cases.
Pedodontic swallowing breathing researcher.
Loma Linda Dental School.
Co-Owner, InnerSmilePro.

8. SWALLOWING FUNCTION and STRUCURE. Concept of degree of difficulty
SWALLOWING FUNCTION and STRUCURE. Concept of degree of difficulty. Neutral Zone – Neutral Matrix. Ortotropic. Phagias.

9. DEVELOPMENTAL PHYSIOLOGY,ORAL HEALTH and INNER SMILES
It is commonly acknowledged that structural lesions produce disturbances of function. Muscular imbalance, ineffective motor patterns and postural strain cause symptoms by themselves and often precede structural changes.
from Brownstein, B. and Bronner, S.
Functional Movement in Orthopaedic and Sports Physical Therapy:
Evaluation, Treatment and Outcomes (1997, p. 159)

10. PHYSICAL THERAPY?
ORAL EXERCISES?
EXERCISES for INNER SMILING?
“General exercises may neglect individual muscle contributions to specific movements. If an inhibited muscle is not firing, continued practice of that exercise may never trigger it, thus perpetuating and possibly amplifying impaired muscle function and imbalances.”
from Brownstein, B. and Bronner, S.
Functional Movement in Orthopaedic and Sports Physical Therapy:
Evaluation, Treatment and Outcomes (1997, p. 159)

11. 1. Biofeedback Billing Codes
AMERICAN PRACTICES ONLY.
Who pays?
1. Biofeedback Billing Codes
90901
90875
90876
90911
2. Evaluation
Six Sessions
Re-Evaluation

12. The Problem:
Oral Habits Can lengthen and reverse any Bite Normalization Procedure.
Blocked airways are emerging as a MAJOR cause of Bite Regression.
Tongue-Thrusting mouth devices do not open airways nor reverse habits.
Oral Habits – grinding*, bruxing*, poor posture- also add to Bite Regression.
* Bruxing and grinding will not be covered in the presentation. We have other software to specifically address the behavioral aspects of these issues.

13. The Good News:
Oral Habits can be reversed in an average of 6 sessions for Class II Open Bites. The need for follow-up visits are re-evaluated at that time, especially if severe Class III.
This finding has been replicated in 3 counties over 27 years.
The effect is not due to placebo effect and is in most cases, permanent.
Habit Retraining can be done in about 20 minutes.

14. Background:
Historically Awareness Training began before the computer, as
‘Manual Awareness Training.’ developed by Dr. Gugino in the 1970s:
Clinics in France report habit reversal using ‘manual’ – non-computer- techniques- over many sessions.
Computerized versions have been in use since 1990, first in Italy, then Japan, and the USA, called ‘Computer-aided Awareness Training.’:
Computerized Clinics in Japan and Loma Linda report reversals in about 6 sessions.
More difficult cases can benefit from Habit Retraining/Awareness coupled with bite normalization.
Breathing difficulties with mouth breathing can also be reversed with Habit Retraining in many cases (Rule out with NuTom nasal cavity images).
Nasal reflexes can be trained that open up most airways very quickly. These are part of our training program,

15. The Bad News:
Offices are reluctant because no one in their office can do it.
Patients are unlikely to ever go to an out-of-office referral for habit retraining.
Offices are unsure of how to market habit retraining.
Few have ever incorporated behavioral training, and need assistance for marketing, training and payment strategies.

16. SUMMARY: CURRENT BELIEFS ABOUT HABIT TRAINING FOR OFFICES:
There is a common belief that it is too complex for the average office.

17. THE PROCEDURES
So how difficult is it?

18. Take the fear out of what to say.. ‘Neutralize staff fears first!
EVERY STEP IS GUIDED BY A VIRTUAL INSTRUCTOR

19. Respiration and Oral Habits go together.
How we break Oral Habits, using InnerSmilePro. (Next Slide)….

20. ASSESSMENT-BASED EXERCISES TAKES 20 Minutes
POLYGRAPH ASSESSMENT
TAKES 15 Minutes
ASSESSMENT-BASED EXERCISES
TAKES 20 Minutes
SIMPLE HOMEWORK EXERCISES
Monitor Success at next visit
INTERNET-SUPERVISED EXERCISES
Schedule Home Sessions
POLYGRAPH RE-ASSESSMENTS
Re-Assess every 6 sessions

21. PART I: HOW TO FIND WHERE TO BEGIN TREATMENT:
POLYGRAPH ASSESSMENT
KEY: Take a computerized ‘snapshot’ of the mouth and breathing during mouth movements, breathing exercises, different postures and different swallows..

22. Sensor Placement takes about 3 minutes: Heart Rate- ECG Electrodes
Left Masseter
Right Masseter
Digastric (Tongue)
Remember.
Yellow is Tongue..
Respiration Belt
Heart Rate- ECG Electrodes

23. The final result is a polygraph report of reactivity to standardized mouth, posture and breathing exercises.
It looks like this (next slide)…..

24. Typical ‘Swallowing’ Profile
THE RESP-ORAL HABITS ASSESSMENT PROFILE
Quantifying the Functional Matrix .
Left Masseter
Right Masseter
Digastric (Tongue)
ORAL
Respiration
Heart Rate
RESP
Typical ‘Swallowing’ Profile

25. This Polygraph profile provides a wealth of information.
Let’s begin with a look at one component, the DRY SWALLOW.
Dry Swallows can be categorized into 6 different patterns,
Like this (Next Slide)…..

26. SWALLOW TYPES

27. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
The Perfect Swallow
Masseter-Dominant
Tongue-Dominant
Incomplete / Double Swallows
Asymmetric Masseter Swallow
Swallow with poor timing.
THE ORAL COMPONENT

28. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
The Perfect Swallow – which one?
Left Masseter
Right Masseter
Digastric (Tongue)

29. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
Masseter-Dominant
Left Masseter
Right Masseter
Digastric (Tongue)

30. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
Tongue-Dominant
Left Masseter
Right Masseter
Digastric (Tongue)

31. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
Incomplete / Double Swallows
Left Masseter
Right Masseter
Digastric (Tongue)

32. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
Asymmetric Masseter Swallow
Left Masseter
Right Masseter
Digastric (Tongue)

33. BEGIN WITH THE SWALLOW PATTERN: IS IT IN THE NEUTRAL ZONE?
So what does the profile show? Here are a few examples:
Swallow Patterns:
Swallow with poor timing.
Left Masseter
Right Masseter
Digastric (Tongue)

34. MICRO-ANALYSIS OF SWALLOW DYNAMICS

35. The Swallow Pattern needs to be broken down into its components.
Here is the swallow – slow and weak:
But this is a DRY Swallow..
Timing is good:
Masseters contract and release with tongue.

36. The Swallow Pattern needs to be broken down into its components.
DRY Swallow..
Compare it to A Wet Swallow.
Drink 4 oz of water…:
Conclusion: WET or DRY – the muscle activity is still weak.

37. LEFT touches more strongly than right when the Tongue is silent.
Conclusion: WET or DRY – the muscle activity is still weak.
Compare it to Touching Teeth::
LEFT touches more strongly than right when the Tongue is silent.
Take out the swallow and Masseters contract strongly With Asymmetry.

38. Compare it to Tongue Contraction Alone:
REVERSAL: Tongue alone reverses the effect: Right touches more strongly than Left
Conclusion:
Tongue Movement alone is also WEAK.

39. PUT IT ALL TOGETHER AND WHAT DO YOU GET?
TONGUE * TOUCH TEETH * SWALLOW * DRINK
WEAK
STRONG
WEAK
WEAK
Right>Left
Left>Right
Right=Left
Right>Left
Conclusion:
The weak swallow is due to poor tongue control. Swallow timing is good.
Masseter asymmetry is reversed by a swallow or tongue movement.
Bite stabilization is indicated – then retest.

40. RESPIRATION and SWALLOWING
What do you call the swallowing of air?
When does swallowing stop?

41. BREATHING COMPONENT ANALYSIS BREATHING MUST STOP DURING SWALLOWING.
THE RESPIRATION COMPONENT
BREATHING COMPONENT ANALYSIS
BREATHING MUST STOP DURING SWALLOWING.
But where in the breath cycle does a patient stop?
STOP DURING INHALE?
This is bad. It can trigger AEROPHAGIA.
STOP DURING EXHALE? This is normal.
Take a look at the following slide (Next Slide)..

42. Breathing is in BLUE.
TONGUE CONTRACTIONS are in YELLOW.
Tongue
Contraction
On Exhale
EXHALE
So when does the breath stop to swallow?
Here the breath stops during exhale or at the end of exhale.
Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

43. Muscle Fatigue and Swallowing

44. Muscle Fatigue and Swallowing

45. Muscle Fatigue and Swallowing

46. Muscle Fatigue and Swallowing

47. LINKING SWALLOW to BREATHING

48. LINKING SWALLOW to BREATHING

49. LINKING SWALLOW to BREATHING

50. LINKING SWALLOW to Autonomic Balance
Advanced Topic- for a full 4 hours.
Hint: ECG patterns derive a signal which gauges sympathetic dominance.
Sympathetic dominance is linked to the muscle spindle.

51. LINKING SWALLOW PROFILE to TREATMENTS

52. ASSESSMENT-BASED EXERCISES
LINKING POLYGRAPH ASSESSMENT TO TREATMENT PROGRAM
The Awareness Training Flow Chart Decision Matrix – Simplified.
The following charts show a simplified version of the major categories linking assessment problems to treatment exercises.
The details of these 40 exercises will not be presented here.
See Next Slide…

53. (Stabilize Masseters)
RESP-ORAL Decision Matrix
In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……
Balance Bite
(Stabilize Masseters)
Malocclusions
Weak tongue touch
Tongue Awareness

54. RESP-ORAL Decision Matrix
In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……
Productive Swallow
(Head Backwards,Touch,Swallow)
Head-forward problem
Posture Stretch Awareness
Productive Swallow
(Exhale,Touch,Swallow)

55. (Nose Breath, Easy Breathing)
RESP-ORAL Decision Matrix
In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……
Pause on Exhale
(Nose Breath, Easy Breathing)
Restricted Airway
Nose/Mouth
Posture-link
Swallow Recovery
(Inhale, Release)

56. RESP-ORAL Decision Matrix
In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……
Restricted Airway
Nose/Mouth
Mechanical-link
Nose-Dilation Reflex Exercises
Vowels Speech Tongue Awareness

57. RESP-ORAL Decision Matrix
In general, start with ‘component’ exercises and add ‘components’ until you achieve a ‘perfect posture, perfect breath, perfect bite, and perfect swallow’ in that order……
Balance Bite
(Stabilize Masseters)
Malocclusions
Weak tongue touch
Tongue Awareness
Productive Swallow
(Head Backwards,Touch,Swallow)
Head-forward problem
Posture Stretch Awareness
Productive Swallow
(Exhale,Touch,Swallow)
Pause on Exhale
(Nose Breath, Easy Breathing)
Restricted Airway
Nose/Mouth
Posture-link
Swallow Recovery
(Inhale, Release)
Restricted Airway
Nose/Mouth
Mechanical-link
Nose-Dilation Reflex Exercises
Vowels Speech Tongue Awareness

58. MASSETER
EXERCISES
RESP-ORAL Treatment Exercises
We select from over 40 Exercises, individualized for each patient. Here is a partial list of our exercises.
BREATHING
EXERCISES
SWALLOW
EXERCISES
POSTURE
EXERCISES
TONGUE
EXERCISES

59. TWO EXAMPLES –in progress

60. CASE 1 - BEFORE

61. CASE 1 – Post 4 MONTHS

62. CASE I WAS VERY CO-OPERATIVE AND ATTENDED EVERY SESSION
HOW DID CASE I’s RESPIRATION & ORAL HABITS PROFILE LOOK?
Next Slide…

63. CASE 1 – PART I: POOR WET SWALLOW. TONGUE vs. MASSETER ISOLATION TEST
Left Masseter
Right Masseter
Digastric (Tongue)
TONGUE vs. MASSETER ISOLATION TEST
DRY vs. WET SWALLOW
TONGUE
TOOTH
WET SWALLOW
POOR DRY
SWALLOW.
MASSETERS
DORMANT
BETTER WET
SWALLOW.
MASSETERS
BALANCED.
INCOMPLETE SWALLOW.
POOR TONGUE CONTROL
BALANCED MASSETERS
GOOD TONGUE RELEASE

64. CASE 1 – BREATHING NOT DIFFERENT. CHIN POSTURE DIFFERENT.
Left Masseter
Right Masseter
Digastric (Tongue)
INHALE vs. EXHALE SWALLOW
CHIN FORWARD vs. REARWARD SWALLOW
CHIN FORWARD SWALLOW
INHALE
SWALLOW
CHIN BACK SWALLOW
EXHALE
SWALLOW
BEST SWALLOW.
POOR RELEASE
UNABLE TO SUSTAIN..
MASSETERS
DORMANT.
INCOMPLETE SWALLOWS.
POOR swallow
VERY POOR SWALLOW

65. CASE 1 – BREATHING DETAIL..
Breathing is in BLUE.
TONGUE CONTRACTIONS are in YELLOW.
Tongue
Contraction
On Exhale
EXHALE
So when does the breath stop to swallow?
Here the breath stops during exhale or at the end of exhale.
Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

66. END of CASE 1
This case is in progress.. A Reassessment Polygraph will be done soon.

67. CASE 2 – START

68. CASE 2 - Post 7 MONTHS

69. CASE 2 HAD FAMILY EMERGENCIES AND CANCELLED SEVERAL SESSIONS, EXTENDING TREATMENT TIME..
HOW DID CASE 2’s RESPIRATION & ORAL HABITS PROFILE LOOK?
Next Slide…

70. CASE 2 – PART I: THE COMPLETE PROFILE.
Left Masseter
Right Masseter
Digastric (Tongue)
CHIN FORWARD vs. REARWARD SWALLOW
TONGUE vs. MASSETER ISOLATION TEST
DRY vs. WET SWALLOW
INHALE vs. EXHALE SWALLOW
CHEW vs. TALK
POOR DRY
SWALLOW.
MASSETERS
DORMANT
BALANCED MASSETERS
GOOD SWALLOW TIMING
POOR TONGUE CONTROL
BETTER WET
SWALLOW.
MASSETERS
BALANCED.
INCOMPLETE SWALLOW.

71. CASE 1 – BREATHING DETAIL..
Breathing is in BLUE.
TONGUE CONTRACTIONS are in YELLOW.
Tongue
Contraction
On Exhale
EXHALE
So when does the breath stop to swallow?
Here the breath stops during exhale or at the end of exhale.
Conclusion- Normal breathing-swallow inhibition reflex (no AEROPHAGIA).

72. End of CASE 2

73. FREQUENLY ASKED QUESTIONS - …

74. Why include respiration? Aren’t my bite-muscle machines enough ?
NO. BREATHING DEPTH, BREATHING FREQUENCY AND BREATHING INTERRUPTIONS DEFINE THE DEGREE OF DIFFICULTY OF MUSCLE PROBLEMS.
MUSCLE ANAYSIS ALONE WILL BIAS YOUR ANALYSIS:
Bite muscle analysis is great – for bite-balance adjustments. But for thrusting swallowing problems, bite balance alone may be a waste of time. Muscles are active during a swallow. Breathing STOPS during a swallow. We need to see where breathing stops to understand compensations leading to mouth breathing habits.

75. Questions about RESP-ORAL Habit Retraining
WHAT IS IT?: A 15 MINUTE PHYSIOLOGICAL ASSESSMENT OF RESPIRATION, ORAL HABITS AND POSTURE.
WHEN DO YOU START?: DONE AT FIRST VISIT.
WHO WILL DO IT? : BY AN OFFICE ASSISTANT.
WHY DO IT?: 1. TO PRESENT TO PATIENT THE NEED FOR HABIT RETRAINING.
2. TO DOCUMENT A BASELINE FOR BITE-CLOSING PROCEDURES. .

76. Questions about RESP-ORAL Habit Retraining
HOW:DO YOU DO IT?
Explain procedure – use brochure or video.
Attach sensors -
Right and Left Masseter, and Digastric Muscles.
Respiration Belt.
ECG sensors across wrists – autonomic balance and HR.
Run Procedure – Generate a printed report – 10 minutes.
DECISION: Start treatment? Discuss with patient or parents. .

77. MAIN POINTS and CONCLUSIONS

78. KEY ADVANTAGES FOR AN OFFICE PRACTICE…
WE NEED A WAY TO ELIMINATE THE NEED FOR AN EXTERNAL ‘TRAINER.’
RESP-ORAL Dx: TRAIN AN EXISTING STAFF MEMBER TO DO A 15 MINUTE RESPIRATION -ORAL HABITS PHYSIOLOGICAL ASSESSMENT AT FIRST VISIT.
WE NEED A STANDARDIZED WAY TO RANK THE SEVERITY OF NASAL BLOCKAGE AND ORAL HABITS FOR TREATMENT PLAN
RESP-ORAL Tx SCHEDULE WITH REGULAR VISITS – ABOUT 20 MINUTES.
ASSIGN HOMEWORK. EVALUATE/DEMONSTRATE LAST HOMEWORK.
DO SECOND RESP-ORAL Dx AFTER 6 SESSIONS.
REINFORCE WITH FOLLOW-UPS IF NEEDED.
Present Computer print outs of sessions at staff meetings to consolidate total treatment package.

79. 3. WE NEED A SIMPLE, RELIABLE WAY OF GUARRENTEEING THAT A PATIENT IS ASSURED OF PERSONALIZED EXERCISES.
THE POOL OF EXERCISES IS OVER 40, BUT THE NUMBER OF TREATMENT EXERCISES IS SMALL. 70 % OF CASES RESPOND TO 5 EXERCISES.
STANDARIZATION IS BUILT INTO THE GUIDED EXERCISE VIDEOS.
The number of causes for Nasal Blockage and Oral Habits is also quite small:
Overactive Tongue
Poor Bite – Imbalanced Bite – Malocclusion
Head-forward posture.
Blocked nose – mechanical and/or vasoconstrictive.
Oral tics and habits – biting nails, sucking, improper chewing.

80. CONCLUSION:
“Tongue Thrusting” or Reverse Swallow” are descriptive, not diagnostic.
The real question is what is the cause of the problem, and how severe is it.
BAD ORAL HABITS
POOR POSTURE
MOUTH BREATHING
MALOCCLUSIONS
TONGUE-THRUSTING
REVERSE SWALLOW
NERVOUS ORAL TICS
WHAT: ALL OF THESE PROBLEMS HAVE BEEN SUCCESSFULLY TREATED.
WHO: BY OFFICE ASSISANTS, PRIVATE AND GROUP PRACTICES.
WHEN: AT FIRST VISIT.
HOW: USING A LOGICAL ASSESSMENT AND BIOFEEDBACK-AIDED HABIT RETRAINING.
WHY: LONG-TERM TREATMENTS REQUIRE HABIT CHANGE.
GOOD TEETH REQUIRE GOOD HABITS.
THANK YOU

81. END