Hand Tremor with Dental Medicine Implications
This article has a distinctly personal application for me. In May of this year, I experienced elective neurosurgery for a movement disorder defined as Essential Tremor. The disorder of hand tremors in my case was bilateral in nature with the onset of symptoms occurring around age 60. It is believed that approximately 50% of essential tremor patients suffer a genetic-linked cause.
And, in my case the condition was progressively resistant to medication management. A neurologic exam and work-up confirmed the suspected diagnosis. Surgical implantation of electrodes in the brain and a battery controller in the chest has stopped the tremors completely, and has enabled me to resume normal activities of my profession and personal life. An additional test I received before surgery was evaluation for trigeminal nerve involvement as a source of causation. For me the test was negative. Why was the test done? Because there is more to the movement disorder story than meets the eye.
Many of us know that certain medications and mandibular vertical dimension problems can cause symptoms of oro-facial dyskinesia, a movement disorder of the mandible and often the tongue. It is a debilitating condition. What is not generally known is that the impact of altered mandibular vertical dimension can also cause even more complex whole-body effects. Brendan C. Stack, DDS, MS, of Vienna Virginia,1 has done much of the research on trigeminal nerve-related hand and body tremors and his successful work includes treatment of Tourrette’s syndrome as well. I could wish that my case of tremors was trigeminal nerve in origin since the treatment would be non-surgical, but I have learned a lot about centrally-mediated hand tremors and, because of that knowledge—together with Dr Stack’s research—I am able to describe for you the following case of right hand tremor of cervical and trigeminal origin.
Tremors of the hand may represent a variety of possible etiologies and diseases. First and foremost is the dreaded diagnosis of Parkinson’s disease, but hypo- and hyper-thyroidism, heavy metal toxicity, traumatic brain injuries, genetic causes, degenerative neuronal changes and drug interactions are just a few of the other causes that may be possible. The issue of tremor can be catastrophic for an individual, impacting job or employment, social contacts and relationships, even down to the simple tasks such as self-feeding, drinking a glass of water and shaving. The degree of tremor can vary from very mild to severe shaking with often altered postural balance. It affects all waking hours and causes fatigue. Because of the fatigue, one experiences a frequent need for additional rest and sleep.
There is currently an unrecognized class of patients who suffer a variety of symptoms of tremor or whole body postural abnormality and, at times, Tourrette’s syndrome that is of dental origin—that is to say, of the trigeminal nervous system. These patients are at great risk of being misdiagnosed as to the origin of their disorder. The dental medicine management for these disorders begins with testing the mandible to maxilla relationship. The test involves the use of a series of tongue blades, or other spacers, to progressively open the distance between the upper and lower front teeth, often to ten or twelve millimeters. The net result may be a cessation of tremor while the spacers are in place, much to the amazement of the patient. According to Dr. Stack and his team, the increase of the vertical dimension affects the aberrant auriculotemporal nerve impulses that represent a subclinical neuritis affecting the trigeminal spinal neucleus and other closely associated motor neurons. The full description of the neuro-anatomical cascade described by Dr. Stack and team may be found in the Journal of Craniomandibular Practice.2
As will be seen in the following case report, it would be a tragic mistake to assume that all cases of tremors or Tourette’s syndrome must be managed by either medications or interventional surgery. And it would be wise to rule out the trigeminally-mediated cases first, knowing that there is generally a significant lag time of 5 to 10 years for new diagnostic information to become main-streamed in medicine.
A female patient, with tremor of the right hand, was referred for evaluation of migraine symptoms, with the dominant pain complaint being located behind the right eye. The patient had been previously treated with oral orthotic appliances but the results were equivocal.
She had been placed on several migraine medications with some help derived from Maxalt, but medications did not seem to effectively control the headache symptoms. Since the literature suggests that some patients with retro-orbital pain are suffering cluster headache, I placed the patient on oxygen supportive therapy on a prn basis. For about three weeks the oxygen would break the retro-orbital headache pain pattern. There has been a diminishing benefit with the oxygen, but is still somewhat effective unless the patient is in a stressful situation.
She is under the care of a new neurologist, who is attempting to bring up serotonin levels. While this process to control migraine or cluster is ongoing, it was noticed at the exam that the patient had a tremor of the right hand of five years duration. Further inquiry found no familial basis for the tremor of the right hand. Questioning revealed onset of the right hand tremor to be related to a social event whereby the patient was responding to a humorous situation, and threw her head and neck back in dorsal flexion. That movement caused an immediate sharp pain in the lower to mid-neck which was followed by the onset of right hand tremor. Being a right-handed individual, she has had to adapt to using her left hand. Further, no one has identified the cause or treatment for the tremor. Being a tremor patient, myself, I suggested to the patient that we try a test used in dental medicine for tremors and Tourrette’s syndrome. I started first by having the patient turn her chin to the left and then tilt the head to the left shoulder (modified Adson’s test). The result was that the tremor stopped. That was repeated three times with cessation of the tremor each time. I then had the patient open her mouth and I first inserted four spacers, then six spacers. At the insertion of six spacers, with the front teeth closed on the spacers, the hand tremor stopped, including the feeling in the right arm associated with the hand tremor. The spacers were removed and re-inserted four or five additional times accompanied with the cessation of hand tremor each time the spacers were in place.