Last June I sponsored the Chelan Neuromuscular Seminar held under the auspices of the International College of Cranio-Mandibular Orthopedics (ICCMO). The seminar was limited to twenty dentists in order to encourage open dialogue between the participants in a more casual atmosphere than exists at the annual ICCMO conventions. Although Chelan is not a convenient seminar location; dentists came from all over the United States and Canada to hear our featured speaker, Dr. Robert Jankelson as well as Dr. Graham Reedy and myself.
Dr. Jankelson gave a comprehensive presentation on the scientific and political history of neuromuscular dentistry. He was there at the beginning when his father, Dr. Bernard Jankelson developed the neuromuscular concept. Dr. Jankelson practiced dentistry based on neuromuscular concepts over his entire career.
Dr. Graham Reedy, a physician who specializes in sports medicine, has included neuromuscular dental concepts in his differential diagnosis and treatment for over thirty-five years. His perspective on the value of the medical dental neuromuscular interface was enlightening and we were happy he was able to speak at our seminar.
My presentation was focused on the diagnoses, treatment and management of difficult dental cases. Without neuromuscular diagnostic instrumentation these cases could not have been possible nor had such positive outcomes.
The participants noted that the three presenters represented over one hundred years experience in neuromuscular dentistry. The seminar was judged by all to be a success and plans were made for the third Chelan Neuromuscular Seminar in June 2013.
I recently visited the Idaho State University Advanced General Dentistry Residency Program in Boise, Idaho to deliver a presentation entitled “Bruxism, Clenching and Obstructive Sleep Apnea – The Neuromuscular Perspective”. The program in Boise is headed by Pamela Powell, DMD, a neuromuscular dentist and a member of the International College of Craniomandibular Orthopedics (ICCMO). Dr. Powell and her two teenage daughters arranged a wonderful selection of snacks and drinks served during the lecture, therefore assuring the participation of the entire clinic staff. The Idaho State Program trains eight general practice residents annually. Dr. Edward Duncan, an adjunct professor was also in attendance. Although Dr. Duncan has been retired for several years, he continues to impart his knowledge of Neuromuscular dentistry and his wisdom from over 30 years of dental practice to young dentists. During the presentation I had the honor of presenting Dr. Duncan with the ICCMO Honorary Fellowship Award. This award is conferred by the ICCMO Board of Directors in recognition of significant and unselfish contributions to the field of neuromuscular dentistry. Dr. Duncan was surprised to receive the Fellowship and pleased that the clinic staff were all present to celebrate with him. I plan to visit the ISU Dental Clinic again next year for a presentation to the 2011-2012 residents.
Last October, my wife Anna and I attended the 22nd Annual Bernard Jankelson Memorial Lecture Forum in Tempe, Arizona. Dr. Jankelson was internationally known as the father of Neuromuscular Dentistry. The International College of Cranio-mandibular Orthopedics (ICCMO) holds this annual conference in honor of Dr. Jankelson who died in 1987. The speakers were primarily from the United States, but we were also treated to two speakers from Australia this year. For the third year in a row Anna, who works with me as my practice administrator, taught a course in communications and insurance management for the dental staff in attendance.
It was an interesting weekend to say the least. One week before the meeting, I received a phone call requesting I teach a half-day program to clinical staff on using Neuromuscular diagnostic equipment in support of the dentist. Unfortunately, the designated instructor had to drop out at the last minute. Then on my way to the airport, I received a frantic phone call informing me that the doctor who was to teach the second portion of the course on Neuromuscular diagnostics had a medical emergency and was on his way back home to Texas. I was asked if I would teach the course all day. No problem! I spent a delightful day with the clinical staff of several dentists who were new to Neuromuscular dentistry and ICCMO. The first night festivities consisted of the Fellowship Awards Banquet where three ICCMO Fellowships were awarded with all the traditional academic fanfare. The scientific session continued through Saturday and was very sucessful. Anna and I found the meeting was everything we expected, teaching, commeraderie, learning and discussion -which continues long after the conference is over. We are looking forward to the ICCMO International Congress in Vancouver, Canada in November this year.
A complete discussion of the cervical spine and its relationship to the craniomandibular system would require a several day seminar. The comments to follow will begin to develop the impact of mandibular posture to cervical dysfunction and pain. The resting relationship of the movable mandible to the fixed maxilla is influenced by many factors. These include dental occlusion, respiration, TM joint anatomy, muscle function, cervical posture, and tongue position. Of course determining which is the cause and which is the effect is why a comprehensive diagnosis is necessary prior to proceeding with any treatment for craniofacial pain and dysfunction.
In all humans, mandibular orthopedic relationship to the maxilla is determined by maximum tooth-to-tooth position. The muscles, TM joints, and cervical spine accommodate to posturally reposition the mandible in order to allow maximum intercuspation of the teeth. Accommodation to bite discrepancy occurs in the entire upper quadrant, especially the cervical spine and more specifically the upper cervical spine, C-1 and C-2. Structural relationships within the upper quadrant are extremely complex and so entwined that abnormalities or stress within one area can produce pain and dysfunction in another. When the individual’s ability to accommodate is exceeded, symptoms occur.
In patients who present with mandibular orthopedic discrepancy as well as cervical discomfort, jaw orthopedics must be evaluated as the primary or secondary stressor for cervical pain and dysfunction. The proper application of Ultra Low Frequency TENS combined with specific masticatory and cervical muscle response, as revealed through electromyography, provides diagnostic data, which frequently reveals the true source of the patient’s cervical pain. Any treatment recommended can thereafter be directed properly resulting in efficient, effective and lower cost therapy. More regarding this complex subject of Trigeminocervical relationships to come.
Saturday was beautiful in Seattle and normally I would be hiking, biking, or working in my garden. However, on this particular Saturday I was presenting to the Washington State Dental Hygiene Association on the topic “TMJ Facts and Fallacies”. My presentation offered a primer on current craniofacial pain (CFP) diagnosis and treatment as well as information to assist dental hygienists in developing a CFP screening program in their practices. Current guidelines and recommendations for CFP screening were also presented.
Dental hygienists are an important part of the dental diagnostic team and patient education is one of their prime prerogatives. CFP complications often affect the dental hygienist’s ability to achieve treatment objectives.
A local production company professionally recorded the presentation and following the editing process and I hope to offer a CD of this presentation on my website.
I hope I am invited for a return presentation in the future. Congratulations to the WSDHA for a great conference and Thank You!
Retro orbital pain, or pain behind the eye, is a frequently reported symptom by patients who have TMJ/TMD. This type of pain is often not perceived to be related to TMD by the patient or the doctor. Patients may have often been convinced that the pain is due to eyestrain or even an undiagnosable or untreatable condition, which only increases their anxiety or depression. It is well known that retro orbital pain can be referred from a trigger point. A trigger point is a hyperirritable spot in a muscle that is painful to palpation. It is called a trigger point because it “triggers” a painful response. A trigger point is more than a tender nodule. It affects not only the muscle within which the trigger point is located, but also causes “referred pain” to distant and seemingly unrelated sites. Trigger points are located in a taut band of muscles fibers. The trigger point is the tenderest point in the band. In the case of eye pain, trigger points are known to be located in at least eight muscles of the head and neck (sternocleidomastiod m., temporalis m., splenius cervicus m., masseter m., suboccipital group, occipitalis m., orbicularis oculi m., and trapezius m.).
The majority of TMD complaints are of muscle dysfunction origin and every patient should be carefully examined of myofascial trigger points, which can be associated with their symptoms. Of course, these muscles are all paired and therefore the muscle on the affected side will refer the pain. The majority of TMD complaints are of muscle dysfunction origin and every patient should be carefully examined for myofascial trigger points, which could be associated with some of their symptoms. Following a comprehensive diagnostic evaluation, if trigger points are identified, these areas should be treated and eliminated prior to any significant surgical or medication intervention.
Our experience with headache patients is typified by our patient Beth (the facts of this case are true, only the names have been changed to protect the innocent.) Beth was referred to me by a neighbor for evaluation of chronic jaw dysfunction including clicking and popping jaw joints, jaw-locking open and closed, and jaw muscle pain. Other significant complaints included chronic severe migraine headaches, frontal headache, occipital headache, and neck pain. She was under the care of her physician for migraine headache treatment with daily medication and 1-2 visits weekly to the hospital emergency room for injections. She was also receiving chiropractic treatment 2-3 times weekly for neck pain.
A complete craniofacial pain diagnostic workup was performed in my office. The results of these evaluations revealed Beth suffered severe jaw muscle dysfunction, chronic jaw muscle spasm, and moderate destructive bone changes in her jaw joints. Careful analysis of jaw muscle and temporomandibular joint function using electromyography and computerized jaw motion analysis indicated a removable oral appliance could correct many of the jaw movement problems. The removable orthotic was delivered and Beth was instructed to wear the orthotic at all times.
Within the first week of wear, she had a dramatic reduction in her headache intensity and frequency. From the first week, Beth never again needed to go to the emergency room for headache treatment. Over the following months, her chiropractic adjustments were reduced and she no longer required prescription headache medication. At approximately 14 months, the orthotic wear was gradually reduced to nighttime wear only. At her 5-year follow-up evaluation, Beth continued to be virtually headache free. Her current dominated complaint is continued neck pain, which is controlled by chiropractic treatments 2-3 times monthly. Beth continues to wear her oral orthotic every night and there has been no further destruction of the jaw joint bone.
Unfortunately, Beth suffered for many years inspite of regular medical, dental, and chiropractic care by good caring doctors doing the best they could to help her. The problem was they simply were not trained to recognize the signs of jaw dysfunction, which had been present for years. It was Beth’s neighborhood friend, a chiropractor, who made the connection and as a result changed Beth’s life for the better.
Headache (cephalgia) is a common complaint among TMD-TMJ patients. Consulting the literature on the incidence of headache yields widely varying results in study populations. This is due to the wide variety of craniofacial pain symptoms, including headache, and the various methods used to categorize headache pain. In spite of this epidemiologic confusion, there are some things we “kind of” know about TMD and headache. Based upon current studies it seems that between 14% and 26% of all headaches are associated with TMD and over 90% of TMD patients list headache as a primary symptom. Muscle tension headache appears to be the dominant type of headache and may be mild or debilitating. Migraine headache is also strongly associated with TMD. Although published studies offer scarce information on this relationship, clinical observations support the consideration of TMD as a cause of significant numbers of migraine headache.
In my own practice over 80% of TMD patients presenting with migraine type headache achieve significant or total relief. As with all medical disorders, a very thorough diagnosis with identification of contributing factors is key to effective therapy. In my experience, deficiency of diagnostic evaluation is the chief cause of treatment failure.
It is a matter of common sense that a direct impact to the lower jaw, temple, or temporomandibular joint can result in injury to the TM joint. A lesser-known mechanism of injury is the TM joint injury resulting from trauma to structures, which directly or indirectly provide attachment to or are functionally related to jaw biomechanics. Neck whiplash injuries are a common cause of late onset symptoms of jaw dysfunctions. Several scientific studies have looked at this specific relationship. The most recent study by Sale and Isberg, published in the Journal of American Dental Association in 2007, reported the incidence of new TM disorder symptoms was 5 times higher in the whiplash injury group as compared to the control group. In the whiplash group, 2 out of 3 patients reported onset of symptoms within 12 months and 20% of the whiplash group stated TMD as their major complaint. Our clients often present with TMD complaints months or years following their whiplash injury without ever having been evaluated for TMD prior to settlement for medical cost of treating the whiplash injury to their neck. TMD treatment then becomes an out of pocket expense and cost alone may prevent the injured person from receiving effective TMD treatment.
The important points to remember are
1) Cervical whiplash alone without direct impact to the temporomandibular structures results in the development of significant TMD complaints in 2 out of 3 whiplash injuries
2) If yourself, a friend or a loved-one suffer a neck whiplash injury from a fall or motor vehicle accident, monitor closely for at least 12 months for the development of possible TMD related symptoms
Patients frequently present with mysterious pain or other symptoms in the head and jaws, which they do not associate with jaw dysfunction (TMJ-TMD). Recently a woman presented with the primary complaint of ear pain. Thinking she had an ear infection, she sought care from her primary physician and an ENT (ear, nose, and throat physician). Both assured her there was no evidence of infection but they did not have an explanation for the pain and gave no recommendation for treatment. She explained to me that although her jaw joints clicked and popped, she did not experience jaw joint pain or limitation of movement. She had come to see me on recommendation of a friend and was uncertain how a dentist could help her ear pain. The explanation of the mysterious ear pain is actually well understood. The ear pain was what we call “referred pain” resulting from pinching of a branch of the auriculotemporal nerve as it passes thru the temporomandibular joint on its way to the inner ear. Treatment of the underlying jaw dysfunction resulted in relief of her chronic ear pain.
One of the challenges to effective treatment of chronic head and jaw pain is proper diagnosis of the cause, which is often not immediately apparent.