1. TMD/MIGRAINE THERAPIES SEMINAR

2. INTRODUCTION
Approximately 37% of people in the USA have symptoms of TMD
Most of them are women. 15% of these people have Migraines.
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.

3. 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”.

4. Dr. Terry Tanaka in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition
“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.

5. Dr. Terry Tanaka in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition
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).

6. The head and face are the focus of much human activity
The 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.

7. The head and face are the focus of much human activity
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.

8. Charles McNeill DDS, Loma Linda Dental School, in his seminar: “Demystifying TMD”
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”.

9. 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.

10. Neuromuscular Patterns
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?
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.

11. We also need to consider the following:
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?

12. We also need to consider the following:
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?

13. We also need to consider the following:
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?

14. We also need to consider the following:
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?

15. Every one talks about TMD, but not many dentists treat it
Dr. Christensen says that general dentists should be treating these patients on a regular basis
(Dr. Christensen said in Dentistry Today Feb 2000)
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.

16. Every one talks about TMD, but not many dentists treat it
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.
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)

17. What’s In A Bite?
By Robert Supple DMD. Dr. Supple graduated from Tufts Dental in He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain
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.

18. What’s In A Bite?
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.

19. What’s In A Bite?
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 He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

20. The million dollar question is
“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 He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)
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.

21. The million dollar question is
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 He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

22. The million dollar question is
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 He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

23. Dr. Peter Dawson explains in a similar way in his textbook, “Evaluation, Diagnosis, and Treatment of Occlusal Problems”
“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.”

24. Studies have shown
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.

25. Studies have shown
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.

26. What other components may be involved?
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.
Slides courtesy of Dr. Robert Supple “Digital Occlusion/Habitual Patterns” research article
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 He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)
Dr. Janet Travell[i], 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.) Travell J. Simons D. Myofascial pain and dysfunciton the trigger point manual. Lippincott williams & wilkins Volume 1: 279
**The HFP 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.

27. What other components may be involved?
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 He is a graduate of Pankey Institute and is currently active in the American Equilibration Society and the American Academy of Craniofacial Pain)

28. What other components may be involved?
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 Volume 1: 279

29. What other components may be involved?
**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.

30. See slide #32 and #50 for more Tscan details.
Tscan Digital Imaging
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.

31. Tscan Digital Imaging
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.

32. Tscan Digital Imaging Continued
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.
Slides courtesy of Dr. Robert Supple “Digital Occlusion/Habitual Patterns”
Fractured distal/lingual cusp on #19, the Distal Lingual of # 18 will be the next cusp to fracture

33. Tscan Digital Imaging
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.
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.

34. Para functional habits
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.
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.

35. Dr. Peter Dawson said:
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)

36. How important is occlusion?
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.
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)

37. How important is occlusion?
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.

38. How important is occlusion?
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)

39. What is pain?
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 long-term use of tranquilizers, antidepressant medications and narcotics.

40. What is pain?
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.
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.

41. What is pain?
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.

42. Importance of a comprehensive diagnosis
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.

43. 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.

44. 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.
Remember, Dr. Terry Tanaka, in his book, TMD and Restorative Dentistry, A Common Sense Approach 6th Edition, said: “Patients want to be listened to and understood. It sounds simple, but not all 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”.
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 gradually helps to heal these areas.

45. 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?

46. 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.

47. 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.

48. 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.

49. 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 help to understand how that might be accomplished and provide some insight and ways that help to reset nerve pathways.

50. 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.

51. 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.
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.

52. 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

53. 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)

54. 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.

55. Therapy Equipment Tscan Digital Occlusion
Occlusal Therapy: We use the Tscan digital computer system for evaluating, adjusting and balancing occlusal related interferences.
2D Moving Picture D Moving Picture
We have been using the Tscan digital computer evaluation for over 20 years. We, and our patients appreciate the fact that we can store each picture and compare the pictures at subsequent visits. Plus we can show the patients, 2D and 3D multiple changing picture color bars and percentage of force differences for each area of tooth contact at any moment of time as they are trying to bite and go into excursions. Each movie is a summary of multiple frames of force in sequence, showing how the force cycle is transferred to the occlusion. Patients relate to and readily understand the visual approach to occlusion, using the Tscan. It helps them visually and mentally, to better understand the cause of their condition and it’s treatment. When they more fully understand their condition and all its interrelated connections, they become more compliant to our treatment protocols and strive to become part of the process. This compliance greatly improves the potential for improvement in their condition.

56. 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.

57. Tscan Use and Explanation Continued
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.

58. 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.

59. 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.
Use of home microcurrent equipment
Proper use of ice and heat and stretching exercises
Home products for inflammation control and for healing of muscles
Things that are harmful to their health and helpful
Anxiety and stress control techniques

60. 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

61. 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.

62. 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.

63. 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

64. 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.

65. Research Articles
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.

66. Research Articles
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;7:52-57.

67. 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).

68. Biomechanical Relationship Between Head, Neck and Teeth Continued
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 atlanto­-occipital 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.

69. Biomechanical Relationship Between Head, Neck and Teeth Continued
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.

70. 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).

71. Biomechanical Relationship Between Head, Neck and Teeth Continued
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 over- recruitment 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.

72. Possible Therapy Protocols
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.

73. 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.

74. Ultrasound Therapy By Our Therapist
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.

75. 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.

76. Massage Therapy By Our Therapist
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.

77. Massage Therapy Continued
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.

78. 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.

79. Alpha-Stim Therapy Continued
Most TMD patients that have had these symptoms for a long time will usually not feel anything from the Alpha-Stim, 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.

80. Alpha Stim Therapy Continued
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.

81. Laser Therapy
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.

82. 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.

83. 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.

84. 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”.