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9 Articles in Volume 10, Issue #4
Chaos (Nonlinear Dynamics) and Migraine
Enhancement of Nerve Regeneration by Therapeutic Laser
Functional Capacity Evaluation (FCE)
Making Practical Sense of Cytochrome P450
Non-pharmacologic Treatment of Shingles
Pain, Neurotechnology, and the Treatment-enhancement Debate
The New Age of Prolotherapy
Treating Myofacial and Other Idiopathic Head and Neck Pain
Treatment of Painful Cutaneous Wounds

Treating Myofacial and Other Idiopathic Head and Neck Pain

Neuromuscular dentistry looks at the system as a whole—including teeth and bones—together with a comprehensive evaluation of the musculature involved.

There are a number of different issues that come to rise in both the physician’s office and the dental practice. One that has surfaced is the prevalence and subsequent treatment of head and neck pain. The problem is that, for people who suffer with such pain, there has been little that can be done to help remedy the problem and patients go through a fairly typical pathway ultimately feeling that there is little to no hope. Throughout time, headaches have plagued people and various solutions have been tried and abandoned. Despite advances in modern healthcare, real answers still do not exist for a number of problems our patients deal with.

It would not be appropriate to claim a panacea for multi-factorial issues or to promote a singular approach of treating every collection of symptoms that hints at head and neck pain, however there are some incredibly interesting developments in the field of dentistry that would be of major benefit to the primary care physicians and those who deal with issues of pain in the head and neck. It is analogous to the story of several blind people who each described an elephant. Since none could see the whole elephant, their impression of what an elephant looks like was totally dependent on the picture in their mind’s eye based on what they feel. The man feeling the tail, the one feeling the leg, the one feeling the belly, and the one feeling the trunk will see, in their mind’s eye, a very different animal. And so it is with pain in the head and neck.

This would not be an issue if patients were not still dealing with pain, however the incidence of migraine in the United States is just a little over 10% and the incidence of headache is over 15%. Together that is more than one in four people who are dealing with significant pain and discomfort. As the pain of those patients becomes severe enough that they seek help, they go to the only logical provider—their physician. In many cases, there is some benefit in following advice, managing allergies, controlling food intake or supporting the patient with medication. The interesting thing that has come to light recently is the benefit of support from a dentist who understands and employs physiologic support of comfortable muscles. As a physician treating chronic pain in the head and neck, it is unlikely that the concepts of neuromuscular dentistry will fall into the realm of training. Unfortunately, even most dentists have not been exposed to the neuromuscular approach. Nevertheless, there are a number of dentists around the world who are employing these concepts in the evaluation of their patients and are experiencing excellent results. With this track record of success, it is time to share the benefits of our various perspectives so that we can accurately describe the complete picture and finally get these patients some help.

Historical Dentistry

From the early days, dentists have looked for better ways, including initial skull studies, to be able to provide prosthetic teeth that are comfortable. In order to better support a patient’s dentures, about a hundred years ago dentists started grinding dentures flat so that they hit on both sides at all the time. While this helped to keep dentures seated, it did not actually restore proper functional dynamics. When these concepts were applied to the natural teeth of dentate patients, they led to an opportunity to improve the understanding of the mouth.

In the 1930s and 1940s, the concepts developed were more focused on the importance of the bumps on the teeth. Gnathology was the study of the effect and relationships between the various bumps on the teeth and these concepts would not only enable the prosthetic teeth to function more efficiently, they would also fit better in natural dentition. However, there were still issues with macro-occlusion—the relationship not between the teeth but between the upper and lower jaw. As these issues came to light, the profession was again afforded the opportunity to increase awareness and understanding.

About a generation later, the improved understanding had grown into the widely accepted theories of centric relation-based occlusion. Within this perspective of the ideal function of the jaws, the basic concepts of balanced contacts between teeth were improved and the importance of the bumps and grooves in the teeth was supported. The major benefit is that it allowed for the perspective of macro-occlusion. What this theory purports is that there is a particular relationship between the position of the condyle and the glenoid fossa and, once the jaw is place in and supported in that position, the mouth will function correctly. Unfortunately the theory was lacking because it was based on a skeletal or bone-braced position and the notion that there is a rotation of the lower jaw in, or around, the temporomandibular joints. Considering the condyle or head of the mandible will distort in a pathologic position—as well as the fact that there simply is never a pure rotation around or even close to the joints—this theory falls a bit short of describing proper function of the jaw.

In the early 1970s, a dentist and physician worked together to help to understand the complicated and multifaceted jaw joint and all the implications it brings to our treatment protocols. Based on work by researches such as Dr. Janet Travell and her enormously beneficial perspective of muscle function and physiology, a more complete picture started to develop. The concepts of neuromuscular dentistry began to come together and, through the efforts of Dr. Barney Jankelson, a new and broader understanding of dentistry emerged. The major benefit of this growth is that rather than looking for a static and mechanical relationship to control a very fluid and dynamic system, the key concepts and fundamental perspective is one of soft tissues first. Rather than just looking at the wearing down of teeth, or looking at boney references that are also subject to distortion and physiologic change, it is important to also consider the support muscles as a determinant of jaw health. The key to developing a physiologically-balanced system lies in understanding the physiology of the entire system.

Dr. Janet Travell found that better than 85% of the pain in the body is derived from muscles. In the head and neck, there are over 160 different muscles and they all need to operate in concert to maintain and support a healthy relationship and well-functioning system. If some structural disfunction or malformation prevents this, then the musculature will necessarily be forced to accommodate and adapt. We are observing, through the application of neuromuscular principles in our practice, that for a majority of patients dealing with chronic head and neck pain and a multitude of other symptoms, some of the answer lies in properly supporting the gross morphology of a healthy stomatognathic system. One of the best tools in our armamentarium is ultra-low frequency Transcutaneous Electrical Neural Stimulation (T.E.N.S.) Appling this to cranial nerves V and VII allows neural mediation of the muscles of mastication by acting primarily on the anterior temporalis and the masseters, but also impacting all of the ancillary supporting musculature. In addition, the protocol includes neurally-stimulating Cranial Nerve XI so that the 45-60 minutes of rhythmic pulsing of the musculature will allow the muscles to return to their more optimal physiologic rest. The mandible will also be suspended freely and return to its neutral posture rather than remain in a torqued or twisted accommodative position.

Neuromuscular dentistry simply looks at the system as a whole—including teeth and bones—together with a comprehensive evaluation of the musculature. Over the last 40+ years, during the development and application of these principles, diseases and disorders formerly referred to as ‘Alphabet Soup Syndrome’ started to respond. Now, we are seeing a major benefit in employing this perspective and actually see improper macro-occlusion as the great imposter. When the bite is in a suboptimal relationship, it forces the musculature to endure the consequences and may have consequences that can be as far reaching as migraine-type pain or even parasthesia and altered sensation in the finger tips. Interestingly, there are also numerous reports of helping patients with a diagnosis of Meniere’s Disease. Although this is still largely anecdotal, it is very encouraging.

Neuromuscular Perspective

Various professions and specialties are actively looking for answers to these issues and they each feel they have the market cornered on the cause. From allergies to stress management to a host of other approaches, the solution almost always comes down to management with medication. The question that should be asked: Is there is another option? If we were to forget what we ‘know’ and examine the presenting symptoms more objectively, it may help to provide some insight. When considering what Botox® has done as a remedy, it is truly remarkable. As a totally elective and esthetic procedure, a large number of patients happened to have issues with migraines and after the administration of Botox that pain abated. The obvious action is the toxin’s effect on the anterior temporalis muscle effectively taking it out of function and eliminating any muscle–derived pain.

Taking this to the next step, there are surgeons who recognize that portions of the anterior temporalis are responsible for the migraine-type pain and so they surgically resect the offending muscle tissue. Before resorting to this surgical approach, it is apparent that the intended function of the muscle may help us to derive the root cause so we can direct our therapy at the source. The primary responsibility of the anterior temporalis muscles is to guide the lower jaw into the proper anatomic positions throughout rest and function, and this position is determined by the dentition. If the supporting dentition is in a place that allows the muscles to function effectively and relax appropriately, then we have homeostasis and comfort. If that is not the case, then we either have a sub-clinical dysfunction or an acute problem that is ignored or misinterpreted until it becomes chronic.

Utilization of real-time jaw tracking to determine the macro-occlusion—along with EMG data to evaluate muscle activity at rest and in function—provides a very revealing perspective. With a patient who is in pain, most often the EMG data can be used to guide the jaw into a more physiologic bite relationship or macro-occlusion. Once in this position, a supportive appliance to maintain the presumably comfortable and physiologic relationship can determine if there is the potential for benefit from changing the morphology of the dental arches and macro-occlusion. The appliance that is employed in Neuromuscular dentistry is unlike any other in dentistry because of the intentional method of finding the more optimal relationship. Traditionally, a very mechanical approach is used to make determinations in the lab or in vitro with the hope that it will affect the intended change once transferred back to the mouth. For a neuromuscularly-trained dentist, the goal is to find a position in space that is supported by live EMG recordings indicating an established, new macro-occlusion. This micro-occlusion would maintain the muscles so that at rest they are comfortable or at their maximum action potential. In addition, because they are allowed to attain physiologic rest, they are capable of proper dynamic function when needed. What is accomplished is balance for the musculature so that it can relax and function rather than be maintained in a chronic state of spasm or fatigue.

Neuromuscular Modalities

There is still a great deal of misunderstanding of the intent of neuromuscular dentistry and, in particular, the techniques taught at the Las Vegas Institute for Advanced Dental Studies (LVI). Over the years the concepts of neuromuscular dentistry remained largely obscure until LVI started to explore the science of occlusion. As a leader in live-patient treatment continuing education, LVI is uniquely able to develop and explore modification and improvements in existing treatment protocols. Based on the success of neuromuscular occlusion, LVI began to teach this approach in its curriculum. The resulting feedback of thousands of dentists implementing this approach in their practice has led to the refinement of effective and predictable management of the patient’s bite and, in the process, seemingly unrelated issues have resolved. Patients who suffer from the previously-mentioned collection of symptoms are routinely helped. Essentially, the goal is to guide the patient to a more ideal macro-occlusion that is based on typical vertical as well as A-P and sagital jaw relationships. This is combined with measuring the EMG readings of the muscles to hone in on the most ideal resting position together with relaxing and de-torquing the system with ultra-low frequency TENS. When this is accomplished, the macro- and micro-occlusal schemes support physiological health. The neuromuscular approach has proven to be quite predictable and beneficial in achieving this goal.

“Essentially, the goal is to guide the patient to a more ideal macro-occlusion that is based on typical vertical as well as A-P and sagital jaw relationships.”

The critical first step in neuromuscular dentistry is to determine what the patient’s individual data and workup would suggest is appropriate—then maintain the appropriate macro-occlusion jaw relationship for a period of time and ensure that both subjective and objective improvements are realized. Once that determination has been made, more definitive solutions would be considered, including selective recontouring of teeth, orthodontic repositioning, surgical correction, or restorative reconstruction. As each case is unique, there is no single ‘right’ way to correct the broken down or worn dentition and often the ideal solution will be some combination of approaches. For example, LVI teaches many corrective modalites to match the needs of the individual patient. Examples include orthodontic repositioning of the teeth and orthognathic surgery where the jaws are surgically repositioned. While, surgical resection would eliminate the major pain, it would not address the source and so is incomplete at best. If that pain is also related to a jaw position that is impinging the airway, then it is the opinion of this author that it would be irresponsible to only address the pain. Likewise, covering patients with palliative pain medications without the concurrent evaluation by a trained neuromuscular dentist would fall short of comprehensively managing the patient, and likely would result in the patient needlessly suffering.

Discussion

The unfortunate reality in dentistry is that there is still as much religion as science and far too many dentists look for reasons to believe what they want to be true rather than carefully evaluating what the science will show. Like every instance where we are describing the elephant with our eyes closed, we see the human physiology from our individual medical perspective. What should be done is to simply consider ‘what if’ and see if there is a reason why there are so many different maladies with the same set of symptoms and deemed ‘untreatable.’ Perhaps there is something that ties the picture together but has been heretofore undiscovered. This happens often with co-morbidity where it is prudent to look for the factors that bind it all together.

For example, in a patient with an over-closed bite, what we really have is a hard tissue mechanical component that is resting in a physiologic position that creates a number of issues. In looking at the functional mechanics of the lower jaw, it is literally suspended by a sling of musculature and supporting soft tissues. Within that is a bony structure and attached via periodontal ligaments are the teeth. Recently, it has been discovered that the periodontal ligaments act more as bone sutures than ligaments and when the jaw is in function, the joint across which we see function is between the teeth and not the bones. Traditional approaches focus on the temporo-mandibular joint and find one of almost 30 different definitions of the one true and precise relationship that determines health. On the other hand, if the ‘joint’ across which we see function is actually the teeth, then the question is how to support that joint so that the musculature is also comfortable. Considering Dr. Travell’s work that 85% of the pain in the body is muscle in origin in the first place, it is reasonable to measure the activity levels of the musculature. If those muscles are in a suboptimal functional relationship then there is a physiologic price to be paid. As with any muscle in the body, splinting and spasm could result along with acute and chronic discomfort and pain.

Considering the hard tissue compromises of a bite in a strained position, it is often found that there is a bending of the neck of the condyle. While it is obvious that this would dramatically change the relationship at the TM joint, that seems to be ignored by traditional approaches to dentistry. There is also calcium deposition and breakdown of the articular disk that can occur. While these all have structural surgical solutions, the fundamental starting point should be to eliminate the cause rather than simply treat an effect. Again, this returns the focus to the supporting muscles. By allowing the muscles to function in a way that there is little to no compromise on their part, issues of tinnitus and idiopathic feelings of congestion or stuffy ears can often be very nicely resolved.

The Whole Picture

Another co-morbidity concern is airway. Obviously the oropharynx is a soft tissue-defined space. If the lower jaw were allowed to continue to close past the genetically-engineered design, the soft tissue guarded airway would be impacted with the posteriorization of the lower jaw. As this occurs, there is universally a combined decrease in the AP dimension as well as the lateral dimension of the airway. Often as the lower jaw is distalized there is a resulting posterior displacement of the tongue. With the only place that would conveniently accommodate that extra tissue being the airway, there is a resulting constriction in the airway at the distal base of the tongue. This diminished airway is commonly found in patients who suffer with sleep apnea and other sleep breathing disorders. The challenge is that physicians who are treating sleep issues are relying on the dental profession to manage the bite. The dental profession is largely unaware of the impact of the bite on airway and is not equipped to assist in the management of the patient and so any underlying dental causative issues are not addressed.

When looking at the whole picture, co-morbidities may indicate that a combination approach may well create a huge leap in understanding for all involved. In a number of issues—such as the treatment of chronic pain and migraine-type pain, the management of sleep and airway, and the overall support of health for our patients—it behooves us to take a look at why so many people are seeing success with neuromuscular approaches. When presented with a patient with some or all of these issues, it is important to determine if a neuromuscular approach would potentially benefit by working with a dentist who is well trained in neuromuscular dentistry. Through collaboration, we caregivers can learn to see the whole picture and field a complete diagnosis as well as a comprehensive approach to supporting sustainable head and neck health.

Summary

There is a major health concern in the adult population that has been ignored or relegated to second tier maladies. Perhaps it is because of the social pressure to not admit pain or headaches. Perhaps the issue arises from a perceived weakness or simply not wanting to be a burden. However, the simple fact remains that head and neck pain is costing our country millions in missed work and man hours. There are tens of millions of people who are suffering on a daily or weekly or monthly basis. There are tens of millions of people who are dealing with an issue that, at best, is inconsistently managed and unpredictably helped. There are a wide variety of approaches to helping these patients and though many will provide some benefit, very few are universally helpful. The missing piece is very likely something that has fallen between the health care professions and is costing our mutual patients a lifetime of pain and discomfort.

There is a reason that patients seem to stop having migraines when they lose their teeth. There is a reason that Botox is effective at temporarily mitigating headache pain. There is a reason that removing part of the anterior temporalis muscle will help to eliminate headache and migraine pain. The good news is that there is also a reason that allowing the muscles of mastication to find their physiologic resting position eliminates head-ache pain. If the lower jaw were stabilized in a place where the supporting musculature is allowed to passively rest, the very predictable result is that head and neck pain is minimized or eliminated—regardless of the diagnosis.

While it is certainly possible that there are multiple issues at play—and every effort should be taken to allow the patient the best chance at comfort—what is also obvious is that, in light of the successes found using the neuromuscular approach in evaluating the stomatognathic system, it would be irresponsible to not consider a complete dental diagnosis that includes real-time EMG information and jaw tracking and, if indicated, relax the muscles of the face by neural stimulation of Cranial Nerves V and VII and XI. What is consistently found is that, in the hands of a properly trained dentist using the protocols as taught at LVI, we have the ability to improve the quality of life of nearly every patient who is dealing with head and neck pain. In issues of co-morbidity, the ideal solution will be in co-managing the treatment. It is only in broadening our perspective that we can see the whole picture. It is only with the proper perspective that we can focus on the offending source. Working together we can make a dramatic difference for our patients.

Last updated on: January 5, 2012
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