Headaches and Chiari Malformation
comments : I am 25 years old and am suffering from headaches. I have had a headache every second of every day for the past 11 months. I saw a neurosurgeon who diagnosed me with a small Chiari Malformation that was constricting the flow of my spinal fluid. He performed a decompression surgery with the hope that my headaches would be relieved. It has been almost 8 months since the surgery, and I have found no relief. He prescribed me a couple of different narcotics, but I experienced no pain relief.He had me make an appointment with a headache specialist whom I will not be able to see for another month. I have, however, been seeing a Nurse Practitioner in the neurologist's office who has placed me on several tryptan medications (I have tried four so far). I was placed on Topamax, but it had no effect, and I developed kidney stones (a known side effect). She also had me take muscle relaxers for a month to see if they would have an effect on the pain, but they did not. I am curre
ntly on Keppra (500 mg a day). I have only been on it two weeks, and the severity of my headaches has increased. I have ocular symptoms as well, shadows and spots in my field of vision, which an opthamalogist believes are a result of the headache. Since I was 11 years old, I have had difficulties with my left temporomandibular joint. I have pain if I open my mouth to far, as well as the common popping and scraping soulnds. My jaw has become increasingly stiff over the past several months. The constant pain is wearing me down and making it difficult to concentrate in school as well as perform my job at a daycare due to my sensitivity to sound. I do not know if there is any type of advice or information you can offer me, but I would appreciate your consideration. HEATHER
Dear Heather
While they found the Chiari malformation because they investigated your headache symptoms that does not mean that it was the cause of your pain initially. It is relatively common to have an assymptomatic Chiari malformation. Because that did not help your headache pain it probably was not the cause of the pain but rather a accidental finding. The malformation was not new, only the severity of the pain was new.
The majority of headaches are related to problems or disturbances of the trigeminal nervous system. With your history of jaw problems and I would tell you to consider trying a DIAGNOSTIC Neuromuscular Orthotic. It is rare for patients not to have significant relief from an orthotic. That does not mean 100% relief. I tell my patients that we initially seek 50-80% relief and then seek 50-80% reduction in residual pain. I frequently get out of town patients who come to Chicago but I will be glad to work with your Neuromuscular Dentist to help you through this difficult time. Frequently trigger point injections and or SPG nerve blocks can be helpful in treating pain problems similar to yours.
I am leaving the country for the next couple of weeks but please feel free to contact me again.
Thursday, December 31, 2009
Saturday, December 26, 2009
Treating Cluster Headaches with High Flow Oxygen appears effective.
According to a new study in the December 9, 2009 issue of JAMA treatment of cluster headaches with high-flow oxygen created pain free relief with-in 15 minutes. The study by Anna S. Cohen, Ph.D., M.R.C.P., of the National Hospital for Neurology and Neurosurgery, London was a randomized, placebo (room air)-controlled trial of high-flow oxygen for the treatment of acute attacks of cluster headache.
Cluster headaches normally have a duration of 15 minutes to 3 hours and the bouts are known for excruciating pain when left untreated. Patients can have as many as 8 attacks a day. The name "cluster Headaches" is because the attacks occur in clusters that last for several weeks or months followed by spontaneous remissions that can last for months to several years. The headaches are currently treated with injections of sumatriptan. This drug can be dangerous due to the frequency of use with clustr headaches.
The Dr Cohen's study included 109 patients, the fian analyzed group include 57 episodic cluster headache patients and 19 patients with chronic cluster headaches. Dr Cohen and the other authors wrote "To our knowledge, this is the first adequately powered trial of high-flow oxygen compared with placebo, and it confirms clinical experience and current guidelines that inhaled oxygen can be used as an acute attack therapy for episodic and chronic cluster headache,"
"This work paves the way for further studies to optimize the administration of oxygen and its more widespread use as an acute attack treatment in cluster headache, offering an evidence-based alternative to those who cannot take triptan agents."
The use of Qxygen is a logical alternative to triptan drugs. It has long been known that cluster headaches responded well to oxygen but this study will pave the way for safer treatments utilizing oxygen. The real question is why did it take so long for this study to be done? That is probably because most of the research is funded by drug companies. They pay for studies when they will then sell expensive products in the future. Dr Cohen and her colleagues have done a huge service to patients suffering cluster headaches by offering a safe and inexpensive alternative to drug therapy.
Sleep apnea is known to cause numerous problems including morning headaches and migraines. Cluster headaches are also frequently during sleep hours. All patients with nocturnal cluster headaches should be evaluated with polysomnography for sleep apnea and Respiratory effort relatedarousals. The drug of choice in sleep apnea is also oxygen but in the form of room air. Opening airway restrictions can eliminate the condition. My I HATE CPAP! site details what happened to my son as a result of sleep apnea. His stroy http://www.ihatecpap.com/dr_shapira.html is a simlilar ending. Treating sleep apnea in children can prevent ADHD. The children heal from breathing. Oxygen not Ritalin is the treatment of choice.
Cluster headaches normally have a duration of 15 minutes to 3 hours and the bouts are known for excruciating pain when left untreated. Patients can have as many as 8 attacks a day. The name "cluster Headaches" is because the attacks occur in clusters that last for several weeks or months followed by spontaneous remissions that can last for months to several years. The headaches are currently treated with injections of sumatriptan. This drug can be dangerous due to the frequency of use with clustr headaches.
The Dr Cohen's study included 109 patients, the fian analyzed group include 57 episodic cluster headache patients and 19 patients with chronic cluster headaches. Dr Cohen and the other authors wrote "To our knowledge, this is the first adequately powered trial of high-flow oxygen compared with placebo, and it confirms clinical experience and current guidelines that inhaled oxygen can be used as an acute attack therapy for episodic and chronic cluster headache,"
"This work paves the way for further studies to optimize the administration of oxygen and its more widespread use as an acute attack treatment in cluster headache, offering an evidence-based alternative to those who cannot take triptan agents."
The use of Qxygen is a logical alternative to triptan drugs. It has long been known that cluster headaches responded well to oxygen but this study will pave the way for safer treatments utilizing oxygen. The real question is why did it take so long for this study to be done? That is probably because most of the research is funded by drug companies. They pay for studies when they will then sell expensive products in the future. Dr Cohen and her colleagues have done a huge service to patients suffering cluster headaches by offering a safe and inexpensive alternative to drug therapy.
Sleep apnea is known to cause numerous problems including morning headaches and migraines. Cluster headaches are also frequently during sleep hours. All patients with nocturnal cluster headaches should be evaluated with polysomnography for sleep apnea and Respiratory effort relatedarousals. The drug of choice in sleep apnea is also oxygen but in the form of room air. Opening airway restrictions can eliminate the condition. My I HATE CPAP! site details what happened to my son as a result of sleep apnea. His stroy http://www.ihatecpap.com/dr_shapira.html is a simlilar ending. Treating sleep apnea in children can prevent ADHD. The children heal from breathing. Oxygen not Ritalin is the treatment of choice.
Addex Pharmaceuticals ends migraine prevention study due to live damage.
The problem with drug therapy for migraines and tension-type type headaches is advers drug effects. This current study was discontinued to a higher than expected amount of liver disorders in patients. The company stated "abnormalities of liver function tests that is higher than expected in this population." Previous studies with this drug had not shown this problem.
the drug being tested ADX10059 is a metabotropic glutamate receptor 5 (mGluR5) negative allosteric modulator (NAM). It is thought that glutamate overstimulation may to contribute via different mechanisms to pathology in both migraine and GERD. The drug ADX10059 has been shown in clinical studies to reduce symptoms of acute migraine and, separately, to reduce reflux and GERD symptoms.
It is assumed the company will retest or reexamine liver function to see if problems were missed on previous studies.
The problems began showing up at day 28 and increased progressively over time. If the problems showed up later such as after 3 months they may never have been found as the study onlyy covered 90 days of treatment.
the drug being tested ADX10059 is a metabotropic glutamate receptor 5 (mGluR5) negative allosteric modulator (NAM). It is thought that glutamate overstimulation may to contribute via different mechanisms to pathology in both migraine and GERD. The drug ADX10059 has been shown in clinical studies to reduce symptoms of acute migraine and, separately, to reduce reflux and GERD symptoms.
It is assumed the company will retest or reexamine liver function to see if problems were missed on previous studies.
The problems began showing up at day 28 and increased progressively over time. If the problems showed up later such as after 3 months they may never have been found as the study onlyy covered 90 days of treatment.
Wednesday, December 23, 2009
severe migraines after surgery.
comments : I first started having very severe headaces about 10 years ago. I went to the doctor and he said I had to see a neurologist. I found out that I had hydrocephlus. I had the surgery and things got better for a little bit. Now the headches are worse. I went back to the neurologist and now he tells me it's migraines. He put me on replax and topomax but they aren't working at all. He just ups the dose. He also told me it has nothing to due with the hydroceophlus. I need help!! I have a major headache a least three times a month. I go to the doctor almost everytime I have one. They give me painkillers but I can tell by the look on their face they think I'm a drug seeker. I'm not I wait as long as I possible can before going to see a doctor for it. Because I know what's in store. Please help me!!!
Response. Obvioualy the drug are not effective. I am glad that you recovered from the hydrcephalus surgery. The pain you now has is not, according to the neurologist related to hydrocephalus and may respond well to a neuromuscular orthotic. I suggest a diagnostic orthotic to evaluate effectiveness of an orthotic as headache treatment initially. Topmax is not effective for over 50% of patients. Most headaches are related to the trigeminal nerve and are helped or eliminated through neuromuscular ental treatment.
Response. Obvioualy the drug are not effective. I am glad that you recovered from the hydrcephalus surgery. The pain you now has is not, according to the neurologist related to hydrocephalus and may respond well to a neuromuscular orthotic. I suggest a diagnostic orthotic to evaluate effectiveness of an orthotic as headache treatment initially. Topmax is not effective for over 50% of patients. Most headaches are related to the trigeminal nerve and are helped or eliminated through neuromuscular ental treatment.
Sunday, December 20, 2009
BOTOX VS TOPOMAX IN MIGRAINE TREATMENT
This study in Headache. 2009 Nov-Dec;49(10):1401 was evaluating effects of Botox (onabotulinumtoxinA) vs Topomax (topiramate) on 60 patients (90% female). The reports site that they have similar success however only 40-42% of patients had a 50% decrease in symptoms. 24% in the topiramate had adverse effects from the drugs compard to only 7% in the onabotulinumtoxinA group.
There were adverse reactions (AE) in 9 out of 60 patients. Only 36/60 even lasted the 9 months of the study. It reported
"Forty-one treatment-related AEs were reported in 18 onabotulinumtoxinA-treated patients vs 87 in 25 topiramate-treated patients, and 2.7% of patients in the onabotulinumtoxinA group and 24.1% of patients in the topiramate group reported AEs that required permanent discontinuation of study treatment. CONCLUSIONS: OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of CM. Patients receiving onabotulinumtoxinA had fewer AEs and discontinuations."
The Advantage of Neuromuscular dentistry is a high success rate (80-95% of patients exhibit substantial improvement) and adverse drug reactions are not a problem. This is a relatively short term study and does not address AE's from long term use.
While there is a place for these drugs in the treatment of migraines they definitely have limits of both safety and effectiveness.
An enormous plus with neuromuscular treatment is that significant reductions in Tension-Type headaches, Chronic daily headaches as well as migraine being reduce in frequency and severity. Many additional symptoms are also relieve simultaneously including ear pain, ear pressure, tinnitus or ring in the ear, sinus pain and/or pressure, retroorbital pain, pain and clicking ot the TM Joint (TMJ). TMD is often called The Great Imposter (http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor)
PubMed Abstract
A double-blind comparison of onabotulinumtoxina (BOTOX) and topiramate (TOPAMAX) for the prophylactic treatment of chronic migraine: a pilot study.
Mathew NT, Jaffri SF.
Houston Headache Clinic-Neurology, 1213 Herman Drive, Houston, TX 77004, USA.
Comment in:
Headache. 2009 Nov-Dec;49(10):1401.
BACKGROUND: There is a need for effective prophylactic therapy for chronic migraine (CM) that has minimal side effects. OBJECTIVE: To compare the efficacy and safety of onabotulinumtoxinA (BOTOX), Allergan, Inc., Irvine, CA) and topiramate (TOPAMAX), Ortho-McNeil, Titusville, NJ) prophylactic treatment in patients with CM. METHODS: In this single-center, double-blind trial, patients with CM received either onabotulinumtoxinA, maximum 200 units (U) at baseline and month 3 (100 U fixed-site and 100 U follow-the-pain), plus an oral placebo, or topiramate, 4-week titration to 100 mg/day with option for additional 4-week titration to 200 mg/day, plus placebo saline injections. OnabotulinumtoxinA or placebo saline injection was administered at baseline and month 3 only, while topiramate oral treatment or oral placebo was continued through the end of the study. The primary endpoint was treatment responder rate assessed using Physician Global Assessment 9-point scale (+4 = clearance of signs and symptoms and -4 = very marked worsening [about 100% worse]). Secondary endpoints included the change from baseline in the number of headache (HA)/migraine days per month (HA diary), and HA disability measured using Headache Impact Test (HIT-6), HA diary, Migraine Disability Assessment (MIDAS) questionnaire, and Migraine Impact Questionnaire (MIQ). The overall study duration was approximately 10.5 months, which included a 4-week screening period and a 2-week optional final safety visit. Follow-up visits for assessments occurred at months 1, 3, 6, and 9. Adverse events (AEs) were documented. RESULTS: Of 60 patients randomized to treatment (mean age, 36.8 +/- 10.3 years; 90% female), 36 completed the study at the end of the 9 months of active treatment (onabotulinumtoxinA, 19/30 [63.3%]; topiramate, 17/30 [56.7%]). In the topiramate group, 7/29 (24.1%) discontinued study because of treatment-related AEs vs 2/26 (7.7%) in the onabotulinumtoxinA group. Between 68% and 83% of patients for both onabotulinumtoxinA and topiramate groups reported at least a slight (25%) improvement in migraine; response to treatment was assessed using Physician Global Assessment at months 1, 3, 6, and 9. Most patients in both groups reported moderate to marked improvements at all time points. No significant between-group differences were observed, except for marked improvement at month 9 (onabotulinumtoxinA, 27.3% vs topiramate, 60.9%, P = .0234, chi-square). In both groups, HA/migraine days decreased and MIDAS and HIT-6 scores improved. Patient-reported quality of life measures assessed using MIQ after treatment with onabotulinumtoxinA paralleled those seen after treatment with topiramate in most respects. At month 9, 40.9% and 42.9% of patients in the onabotulinumtoxinA and topiramate groups, respectively, reported > or =50% reduction in HA/migraine days. Forty-one treatment-related AEs were reported in 18 onabotulinumtoxinA-treated patients vs 87 in 25 topiramate-treated patients, and 2.7% of patients in the onabotulinumtoxinA group and 24.1% of patients in the topiramate group reported AEs that required permanent discontinuation of study treatment. CONCLUSIONS: OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of CM. Patients receiving onabotulinumtoxinA had fewer AEs and discontinuations.
PMID: 19912346 [PubMed - in process]
There were adverse reactions (AE) in 9 out of 60 patients. Only 36/60 even lasted the 9 months of the study. It reported
"Forty-one treatment-related AEs were reported in 18 onabotulinumtoxinA-treated patients vs 87 in 25 topiramate-treated patients, and 2.7% of patients in the onabotulinumtoxinA group and 24.1% of patients in the topiramate group reported AEs that required permanent discontinuation of study treatment. CONCLUSIONS: OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of CM. Patients receiving onabotulinumtoxinA had fewer AEs and discontinuations."
The Advantage of Neuromuscular dentistry is a high success rate (80-95% of patients exhibit substantial improvement) and adverse drug reactions are not a problem. This is a relatively short term study and does not address AE's from long term use.
While there is a place for these drugs in the treatment of migraines they definitely have limits of both safety and effectiveness.
An enormous plus with neuromuscular treatment is that significant reductions in Tension-Type headaches, Chronic daily headaches as well as migraine being reduce in frequency and severity. Many additional symptoms are also relieve simultaneously including ear pain, ear pressure, tinnitus or ring in the ear, sinus pain and/or pressure, retroorbital pain, pain and clicking ot the TM Joint (TMJ). TMD is often called The Great Imposter (http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor)
PubMed Abstract
A double-blind comparison of onabotulinumtoxina (BOTOX) and topiramate (TOPAMAX) for the prophylactic treatment of chronic migraine: a pilot study.
Mathew NT, Jaffri SF.
Houston Headache Clinic-Neurology, 1213 Herman Drive, Houston, TX 77004, USA.
Comment in:
Headache. 2009 Nov-Dec;49(10):1401.
BACKGROUND: There is a need for effective prophylactic therapy for chronic migraine (CM) that has minimal side effects. OBJECTIVE: To compare the efficacy and safety of onabotulinumtoxinA (BOTOX), Allergan, Inc., Irvine, CA) and topiramate (TOPAMAX), Ortho-McNeil, Titusville, NJ) prophylactic treatment in patients with CM. METHODS: In this single-center, double-blind trial, patients with CM received either onabotulinumtoxinA, maximum 200 units (U) at baseline and month 3 (100 U fixed-site and 100 U follow-the-pain), plus an oral placebo, or topiramate, 4-week titration to 100 mg/day with option for additional 4-week titration to 200 mg/day, plus placebo saline injections. OnabotulinumtoxinA or placebo saline injection was administered at baseline and month 3 only, while topiramate oral treatment or oral placebo was continued through the end of the study. The primary endpoint was treatment responder rate assessed using Physician Global Assessment 9-point scale (+4 = clearance of signs and symptoms and -4 = very marked worsening [about 100% worse]). Secondary endpoints included the change from baseline in the number of headache (HA)/migraine days per month (HA diary), and HA disability measured using Headache Impact Test (HIT-6), HA diary, Migraine Disability Assessment (MIDAS) questionnaire, and Migraine Impact Questionnaire (MIQ). The overall study duration was approximately 10.5 months, which included a 4-week screening period and a 2-week optional final safety visit. Follow-up visits for assessments occurred at months 1, 3, 6, and 9. Adverse events (AEs) were documented. RESULTS: Of 60 patients randomized to treatment (mean age, 36.8 +/- 10.3 years; 90% female), 36 completed the study at the end of the 9 months of active treatment (onabotulinumtoxinA, 19/30 [63.3%]; topiramate, 17/30 [56.7%]). In the topiramate group, 7/29 (24.1%) discontinued study because of treatment-related AEs vs 2/26 (7.7%) in the onabotulinumtoxinA group. Between 68% and 83% of patients for both onabotulinumtoxinA and topiramate groups reported at least a slight (25%) improvement in migraine; response to treatment was assessed using Physician Global Assessment at months 1, 3, 6, and 9. Most patients in both groups reported moderate to marked improvements at all time points. No significant between-group differences were observed, except for marked improvement at month 9 (onabotulinumtoxinA, 27.3% vs topiramate, 60.9%, P = .0234, chi-square). In both groups, HA/migraine days decreased and MIDAS and HIT-6 scores improved. Patient-reported quality of life measures assessed using MIQ after treatment with onabotulinumtoxinA paralleled those seen after treatment with topiramate in most respects. At month 9, 40.9% and 42.9% of patients in the onabotulinumtoxinA and topiramate groups, respectively, reported > or =50% reduction in HA/migraine days. Forty-one treatment-related AEs were reported in 18 onabotulinumtoxinA-treated patients vs 87 in 25 topiramate-treated patients, and 2.7% of patients in the onabotulinumtoxinA group and 24.1% of patients in the topiramate group reported AEs that required permanent discontinuation of study treatment. CONCLUSIONS: OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of CM. Patients receiving onabotulinumtoxinA had fewer AEs and discontinuations.
PMID: 19912346 [PubMed - in process]
Saturday, December 19, 2009
TMJ AND MIGRAINES
comments : I have TMD - diagnosed by MRI, significant anterior and lateral displacement of the disc on my left side. I have migraines, stomach issues, constant neck and back pain and stiffness and allergies. I also have trigeminic neuralgia - undiagnosed, but the shooting pains in my ear can be nothing else. The ENT specialist says my ears are fine. I had my last migraine for 7 days and I would estimate that I have at least a low grade headache every day. I am at my wits end and I am tired of trying to guess at who can possibly help me. Someone please help.
The MRI explains the joint problem. The rest of the pain is probably neuromuscular. Neuromuscular dentistry can help correct the pain problems but the displaced disk may or may not return to a normal position. It is possible to remain comfortable even though the joint is displaced.
The MRI explains the joint problem. The rest of the pain is probably neuromuscular. Neuromuscular dentistry can help correct the pain problems but the displaced disk may or may not return to a normal position. It is possible to remain comfortable even though the joint is displaced.
Friday, December 11, 2009
An article in Science daily states "To main tain muscle strength with age, cells must get rid of garbage that slowly accumulates in them", TMJ problems and headaches are usually from unhealthy muscles that have taut bands and trigger points. Breaking up of trigger points by injection, massage or other means frequently is referred to as "releasing toxins" and can be associated with diarrhea, nauesau or other symptoms. Massage therapists frequently recomment drinking lots of water to flush toxins. This has been scoffed at by many "real doctors" who consider the idea of toxin release "silly".
The article describes "The cellular junk includes toxic clumps of malformed proteins, pathogens and spent organelles, which are cellular compartments used for specific functions."
The study done on mice by MRCO SANDRI OF THE UNIVERSITY OF PADOVA IN ITALY was published in the Journal of Cell Metabolism. He reported that the muscles were "not happy" when damaged parts were not removed. He described his findings as being similar to what is seen in muscle wasting diseases.
Neuromuscular Dentistry focuses on restoring muscles to a healthier state by using TENS to pulse the muscles. The muscles contract and pump out waste products and the process increases blood flow to take those waste products away and bring in nutrition. If built up waste products causing aging damage than removal of those waste products would reverse that process and could be considered an anti-aging muscle effect.
The basic premise of neuromuscular dentistry is to restore health by setting up an environment where the body can accomplish healing. In neuromuscular dentistry we do hat on a cellular level and on a neurological level.
Doctors do not heal patients. The best we can hope for is to remove the impediments to healing so are bodies can restore themselves to health.
Aging is still consided an inevitable conclusion to life but Aubrey DeGray has painted a different picture. He says all we need to do is fix the seven types of damage and we can reverse or at least eliminate diseases of aging.
Neuromuscular dentistry reverses the damage to the system caused by physiologiclal changes that result from a poorly functioning system. There is a simple logic that each and every aspect of neuromuscular dentistry addresses.
The article describes "The cellular junk includes toxic clumps of malformed proteins, pathogens and spent organelles, which are cellular compartments used for specific functions."
The study done on mice by MRCO SANDRI OF THE UNIVERSITY OF PADOVA IN ITALY was published in the Journal of Cell Metabolism. He reported that the muscles were "not happy" when damaged parts were not removed. He described his findings as being similar to what is seen in muscle wasting diseases.
Neuromuscular Dentistry focuses on restoring muscles to a healthier state by using TENS to pulse the muscles. The muscles contract and pump out waste products and the process increases blood flow to take those waste products away and bring in nutrition. If built up waste products causing aging damage than removal of those waste products would reverse that process and could be considered an anti-aging muscle effect.
The basic premise of neuromuscular dentistry is to restore health by setting up an environment where the body can accomplish healing. In neuromuscular dentistry we do hat on a cellular level and on a neurological level.
Doctors do not heal patients. The best we can hope for is to remove the impediments to healing so are bodies can restore themselves to health.
Aging is still consided an inevitable conclusion to life but Aubrey DeGray has painted a different picture. He says all we need to do is fix the seven types of damage and we can reverse or at least eliminate diseases of aging.
Neuromuscular dentistry reverses the damage to the system caused by physiologiclal changes that result from a poorly functioning system. There is a simple logic that each and every aspect of neuromuscular dentistry addresses.
PERIODONTAL DISEASE, CHRONIC PAIN AND SLEEP DISRUPTION
An abstract in SLEEP, Volume 32, Abstract Supplement, 2009 looks at periodontal disease, an extremely common and chronic inflamatory condition and its effect in animal studies on sleep. The conclusion of the authors was "Our results suggest that PD resulted in marked sleep disruption, especially in non-REM sleep, probably due to the development of orofacial pain."
This is probably a direct result of nociceptive stimulation of the trigeminal nerve causing centrl sensitization. While this was only an experimental animal study on rats it showed reductions in sleep efficiency, non-REM time and increases in arousals.
This is scary data considering the majority of americans have some level of periodontal disease (PD). PD has been implicated in heart disease, stroke, diabetes, increased infections and many other disorders. It has been assumed that this was the result of inflamatory changes in the bloodsteam and body fluids but this study could actually suggest those changes are neurological due to nociception within the trigeminal nervous system.
This is probably a direct result of nociceptive stimulation of the trigeminal nerve causing centrl sensitization. While this was only an experimental animal study on rats it showed reductions in sleep efficiency, non-REM time and increases in arousals.
This is scary data considering the majority of americans have some level of periodontal disease (PD). PD has been implicated in heart disease, stroke, diabetes, increased infections and many other disorders. It has been assumed that this was the result of inflamatory changes in the bloodsteam and body fluids but this study could actually suggest those changes are neurological due to nociception within the trigeminal nervous system.
Posture correction,PPM Mouthguard, leg length and A/o or NUCCA Chiropractic
Slightly rewritten from an LVI forum post explaining to new neuromuscular dentists the importance of body posture and a few of the ways t can be addressed.
I had the supreme honor of studying with Janet Travell and watched her magically turn long legs into short legs and vice-versa. A trick I picked up from her 30 years ago was to correct the standing leg posture, have the patient walk and correct it again. I use paper towels as temporary orthotics in the shoe. I have the patient take short walks and the readjust the foot orthotic (paper towel). It is done easily by feeling the top of he hips with your finger tips and getting them at eye level (patients love having their doc on his knees) after several adjustments it will stabilize.
I take most of my bites standing so I will do this before taking bite or adj. The bite is essential but is not just a record of upper jaw to lower jaw, but rather a way to capture 3 dimensional body mechanics and jaw relatin simultaneously.
I teach the patient how to do this at home. They need a full length mirror and two marker spots on the top of the hip bone. They stand 4-5 feet back from the mirror and hang a black plumb line in the middle of the mirror and can self adj.their orthotics. Initially they will do this several times a day. I Rx they just buy several diffent Dr Scholl pads an self adj frequently. Sometimes the lift will switch sides more than once while the spine staightens itself.
The second trick is to also check the hip height in the sitting position. We use tushy orthotics to even height of hips sitting. It is crucial to know if the high side changes from sitting to standing because it corkscrews the spine and wreaks havoc on the bite. These are the patients whose Atlas is never stable. We send them for Atlas orthogonal adjustment with a leg correction, We have the leg length checked standing before they leave because it may need a change in the orthotic and we check the sitting orthotic because they are sitting in the car going from one office to the other. We frequently have them keep an aqualizer in their mouth or a coton roll as well so we get a/o aj without having it affected by the bite. It would be a whole lot easier if we could just cut the head off and just deal with the bite.
The patient does the same proceedure with the plumb line but sits on a hard flat chair. The patients keep their tushy orthotics in their car, desk chair, couch etc. For long term correction of structural hip deficiecy I have had patients, usually women have them made from bike pants that the pads are adjusted and "tummy control"
If a patient has a structurally short hip on one side sitting and leg length discrepancy on the other we are guaranteeing long term problems and dental failures in the mouth.
It is vital patients do their ascending correction 24/7 or it is the same effect of our orthotics not being left in. Corrections must be continuous.
When I have a patient and we do the pen test (I use cotton rolls easier to adj to improve results) we show them arm strength and balance with the correction then without. I then correct leg length with something under shoe and repeat the test. They get the same results. We then do a double correction to increae strength and balance more and the we blow them away because they lose strength and balance regardless if we take away the shoe lift or the bite correction. They now completely understand ascending/descending concepts.
Now all we have to worry abut is the AP position of spine from hips to head including pelvic tilt and hip rotation and balancing pecs and rhomboids and the effects on jaw relation.
I had the supreme honor of studying with Janet Travell and watched her magically turn long legs into short legs and vice-versa. A trick I picked up from her 30 years ago was to correct the standing leg posture, have the patient walk and correct it again. I use paper towels as temporary orthotics in the shoe. I have the patient take short walks and the readjust the foot orthotic (paper towel). It is done easily by feeling the top of he hips with your finger tips and getting them at eye level (patients love having their doc on his knees) after several adjustments it will stabilize.
I take most of my bites standing so I will do this before taking bite or adj. The bite is essential but is not just a record of upper jaw to lower jaw, but rather a way to capture 3 dimensional body mechanics and jaw relatin simultaneously.
I teach the patient how to do this at home. They need a full length mirror and two marker spots on the top of the hip bone. They stand 4-5 feet back from the mirror and hang a black plumb line in the middle of the mirror and can self adj.their orthotics. Initially they will do this several times a day. I Rx they just buy several diffent Dr Scholl pads an self adj frequently. Sometimes the lift will switch sides more than once while the spine staightens itself.
The second trick is to also check the hip height in the sitting position. We use tushy orthotics to even height of hips sitting. It is crucial to know if the high side changes from sitting to standing because it corkscrews the spine and wreaks havoc on the bite. These are the patients whose Atlas is never stable. We send them for Atlas orthogonal adjustment with a leg correction, We have the leg length checked standing before they leave because it may need a change in the orthotic and we check the sitting orthotic because they are sitting in the car going from one office to the other. We frequently have them keep an aqualizer in their mouth or a coton roll as well so we get a/o aj without having it affected by the bite. It would be a whole lot easier if we could just cut the head off and just deal with the bite.
The patient does the same proceedure with the plumb line but sits on a hard flat chair. The patients keep their tushy orthotics in their car, desk chair, couch etc. For long term correction of structural hip deficiecy I have had patients, usually women have them made from bike pants that the pads are adjusted and "tummy control"
If a patient has a structurally short hip on one side sitting and leg length discrepancy on the other we are guaranteeing long term problems and dental failures in the mouth.
It is vital patients do their ascending correction 24/7 or it is the same effect of our orthotics not being left in. Corrections must be continuous.
When I have a patient and we do the pen test (I use cotton rolls easier to adj to improve results) we show them arm strength and balance with the correction then without. I then correct leg length with something under shoe and repeat the test. They get the same results. We then do a double correction to increae strength and balance more and the we blow them away because they lose strength and balance regardless if we take away the shoe lift or the bite correction. They now completely understand ascending/descending concepts.
Now all we have to worry abut is the AP position of spine from hips to head including pelvic tilt and hip rotation and balancing pecs and rhomboids and the effects on jaw relation.
Coming to Chicago for Treatment
I have had numerous patients come to Chicago for treatment at my Gurnee office. We do have a hotel close to the office that offers special rates to our patients. It is the same hotel that I hold my courses at ane they give us a discounted rate. Patients flying in can use O'hare Airport or Milwaukee's Mitchell Field. We have found that treatment is more efficient for long distance patients if patients are seen on three consecutive days.
Sleep and TMJ Disorders
Patients with TMJ disorders should be evaluated for sleep disorders according to a new article in Sleep. Primary Insomnia was associated with hyperalgesia or an increased pain response. It may also be associated with central senssitazation that is found in migraines, fibromyalgia and TMD and may be a causitive factor in idiopathic pain (pain of unknown orgins)
The NHLBI (National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ disorder. The paper "Cardiovascular and Sleep Related consequences of TMJ Disorders can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
PATIENTS WITH TMJ DISORDERS AND SLEEP PROBLEMS SHOULD BE EVALUATED BY A SLEEP PHYSICIAN! FOR MORE INFORMATION ON SLEEP APNEA, DANGERS AND TREATMENT SEE http://www.ihatecpap.com
MORNING HEADACHES ARE USUALLY THE RESULT OF TMD OR SLEEP APNEA
BRUXISM IS OFTEN A SECONDARY RESULT OF SLEEP APNEA
PubMed abstract is supplied for your convenience.
Sleep. 2009 Jun 1;32(6):779-90.
Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder.
Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA.
Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA. msmith62@jhmi.edu
STUDY OBJECTIVES: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity. DESIGN: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold. SETTING: Orofacial pain clinic and inpatient sleep research facility. PARTICIPANTS: Fifty-three patients meeting research diagnostic criteria for myofascial TMD. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05). CONCLUSIONS: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.
The NHLBI (National Heart Lung and Blood Institute considers Sleep Apnea to be a TMJ disorder. The paper "Cardiovascular and Sleep Related consequences of TMJ Disorders can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
PATIENTS WITH TMJ DISORDERS AND SLEEP PROBLEMS SHOULD BE EVALUATED BY A SLEEP PHYSICIAN! FOR MORE INFORMATION ON SLEEP APNEA, DANGERS AND TREATMENT SEE http://www.ihatecpap.com
MORNING HEADACHES ARE USUALLY THE RESULT OF TMD OR SLEEP APNEA
BRUXISM IS OFTEN A SECONDARY RESULT OF SLEEP APNEA
PubMed abstract is supplied for your convenience.
Sleep. 2009 Jun 1;32(6):779-90.
Sleep disorders and their association with laboratory pain sensitivity in temporomandibular joint disorder.
Smith MT, Wickwire EM, Grace EG, Edwards RR, Buenaver LF, Peterson S, Klick B, Haythornthwaite JA.
Johns Hopkins University School of Medicine, Department of Psychiatry and Behavioral Sciences, Baltimore, MD, USA. msmith62@jhmi.edu
STUDY OBJECTIVES: We characterized sleep disorder rates in temporomandibular joint disorder (TMD) and evaluated possible associations between sleep disorders and laboratory measures of pain sensitivity. DESIGN: Research diagnostic examinations were conducted, followed by two consecutive overnight polysomnographic studies with morning and evening assessments of pain threshold. SETTING: Orofacial pain clinic and inpatient sleep research facility. PARTICIPANTS: Fifty-three patients meeting research diagnostic criteria for myofascial TMD. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: We determined sleep disorder diagnostic rates and conducted algometric measures of pressure pain threshold on the masseter and forearm. Heat pain threshold was measured on the forearm; 75% met self-report criteria for sleep bruxism, but only 17% met PSG criteria for active sleep bruxism. Two or more sleep disorders were diagnosed in 43% of patients. Insomnia disorder (36%) and sleep apnea (28.4%) demonstrated the highest frequencies. Primary insomnia (PI) (26%) comprised the largest subcategory of insomnia. Even after controlling for multiple potential confounds, PI was associated with reduced mechanical and thermal pain thresholds at all sites (P < 0.05). Conversely, the respiratory disturbance index was associated with increased mechanical pain thresholds on the forearm (P < 0.05). CONCLUSIONS: High rates of PI and sleep apnea highlight the need to refer TMD patients complaining of sleep disturbance for polysomnographic evaluation. The association of PI and hyperalgesia at a nonorofacial site suggests that PI may be linked with central sensitivity and could play an etiologic role in idiopathic pain disorders. The association between sleep disordered breathing and hypoalgesia requires further study and may provide novel insight into the complex interactions between sleep and pain-regulatory processes.
Trigger points and referred pain
Dr. Shapira, Thank you for taking the time to answer my question. This answer is one that has help me know what is definately going on in my head and given me a posible remedy to my misery. THANK YOU!!!
The sore spots are from tender muscles and trigger points that cause the headaches.
Neuromuscular dentistry can frequently correct the problem that causes both the headaches and the muscle pain.
The sore spots are from tender muscles and trigger points that cause the headaches.
Neuromuscular dentistry can frequently correct the problem that causes both the headaches and the muscle pain.
Slipping through the cracks between medicine and dentistry
i read your article and found it enjoyable. i can empathize with mary and joyce; losing track of medications which only work to a moderate degree, and seeing countless practitioners. it can be discouraging.
i often say TMD should be reworked into its own field of dental neurology. people with our symptoms very often slip through the cracks between medicine and dentistry. too often my neurologist would say, i don't know, i am not a dentist. conversely, the dentists said, i am not a neurologist. i wonder if medical school and dental schools are doing more to bridge this gap scholastically....
i often say TMD should be reworked into its own field of dental neurology. people with our symptoms very often slip through the cracks between medicine and dentistry. too often my neurologist would say, i don't know, i am not a dentist. conversely, the dentists said, i am not a neurologist. i wonder if medical school and dental schools are doing more to bridge this gap scholastically....
Thursday, December 10, 2009
No pain prior to having anterior appliance
thank you very much for replying.
my family dentist told me i was grinding at night. i had no pain or obvious problems, so i told him to forget it, but he kept insisting. he made me a night guard which looked like a retainer i wore in 7th grade after i had braces. he instructed me to wear it at night, and if i was stressed to wear it during the day.
i wore it from march of 08 and my pain started in august of 08. as a result, i have an anterior open bite. i was told my molars supra erupted because the night guard kept them apart. i was also the the night guard is what *caused* this entire cycle because it loaded my joints and opened my bite.
the orthotic does not control my facial pain. i have tingling in my cheeks, aching, and forehead and scalp aching. my jaw feels tired and has total loss of proprioception.
it does not make sense to me that TMJ can cause the above facial symptoms. do you have other patients with symptoms like mine?
how does one regain the space lost between the condyle and fossa?
Reply
I have seen hundreds of patients with similar symptoms. TMJ disorders are often caused the Great Imposter because so many iverse problems can result. Check out this link for a story I wrote for Sleep and Health.
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor
Did the pain come on sudely or very gradually?
Normally you will not have a lot of supereruption from wearing an appliance only at night? If there is an acute dislocation of the disk it can create problems like you are having.
Do you have a problem opening your mouth wide as that is often seen with acute dislocation.?
my family dentist told me i was grinding at night. i had no pain or obvious problems, so i told him to forget it, but he kept insisting. he made me a night guard which looked like a retainer i wore in 7th grade after i had braces. he instructed me to wear it at night, and if i was stressed to wear it during the day.
i wore it from march of 08 and my pain started in august of 08. as a result, i have an anterior open bite. i was told my molars supra erupted because the night guard kept them apart. i was also the the night guard is what *caused* this entire cycle because it loaded my joints and opened my bite.
the orthotic does not control my facial pain. i have tingling in my cheeks, aching, and forehead and scalp aching. my jaw feels tired and has total loss of proprioception.
it does not make sense to me that TMJ can cause the above facial symptoms. do you have other patients with symptoms like mine?
how does one regain the space lost between the condyle and fossa?
Reply
I have seen hundreds of patients with similar symptoms. TMJ disorders are often caused the Great Imposter because so many iverse problems can result. Check out this link for a story I wrote for Sleep and Health.
http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor
Did the pain come on sudely or very gradually?
Normally you will not have a lot of supereruption from wearing an appliance only at night? If there is an acute dislocation of the disk it can create problems like you are having.
Do you have a problem opening your mouth wide as that is often seen with acute dislocation.?
Facial Pain and Bite Changes after anterior appliance
comments : i wore an anterior nightguard which changed my bite. i now have an open bite. only one molar touches down. a few months into wearing this night guard, i had a sudden onset of excruciating tooth pain which started on one side of my teeth and spread to the other side within one week. the nerves in my face were also affected as my cheeks ache and also my forehead and scalp. my neuro says i do not have TN but my nerves are irritated. the only thing which helped was a lower mandibular splint. it took my teeth pain away within a few weeks however my bite is still open when i do not wear it. what do i do next? how do i take the pain away for good? can a bite change cause al this face pain? i never get headaches, only facial and tooth pain. my TMJ joints are only 4mm, and were pushed up and back into the upper part of my skull. the discs are both displaced. i have no space left in between either joint and the upper part of my skull. i am on an anti convulsant, and an anti
depressant for pain control, it is helping somewhat. please advise. Kristin
depressant for pain control, it is helping somewhat. please advise. Kristin
Reply
You did not state what symptoms you were having when you started wearing the first nightguard or whether you had an anterior or posterior open bite. It is obviously a long-term condition because of the bilaterally displaced disks. Very often when you wear an oral appliance you have healing of oral structures resulting in bite changes. If the mandibular appliance is controlling the pain you may want to continue to stabilize and refine your bite. The orthotic can be a guide for future definitive correction of the bite.
Very often orthodontics, restorative dentistry, reconstruction or long term orthotics are necessary to complete a case. I usually try to avoid surgical intervention. The anterior appliances like the NTI are easy to make and are ideal for some patients but can lead to loose or sore teeth and orthopedic changes. Long term use of a lower appliance can also make those changes long lasting. For most patients I use neuromuscular orthotics.
In my practice we do a phased treatment.. The first phase is elimination of symptoms. When I use orthotics they are on the mandibular teeth and are worn 24 hours a day. We always explain before starting treatment that a second phase may be necessary to complete the case. When the symptoms are relieved (You are not yet there) we consider long term correction.
Wednesday, December 9, 2009
Headaches after subdural hematoma
I had brain surgery for a subdural hemotoma on the left frontal lobe. I have recurring ten point headaches that hit like a meteor and dissapate quickly and some that are a nagging, spreading pain that goes down my neck and sometimes back.
It sounds like you have recovered from the surgical proceedures after the Hematoma. You did not say how long ago it originally happened or what the originally caused the hematoma. Was it due to traumatic incident?
The nagging, spreading pain that goes down your neck and sometimes into your back is probably muscular in orgin and may respond well to treatment with Neuromuscular dentistry but a lot more information is needed. You stated that the pain goes down your neck but even though it feels like that, they may actually be pains comig up from the back to the neck. Neck and back pain are closely related to jaw pain due to posture. Your exam should include a thorough muscle palpation exam to evaluate trigger points and sore muscles.
The suden shooting headaches are probably neurologic in nature and I hope you have discussed them with your neurologist. That pain may have a specific trigger. It may or may not be affected by neuromuscular orthotic treatment. When you receive an orthotic it can help problems that are due to nervous overload.
Aqualizer
Patient Inquiry:
My now 25-year old daughter was poisoned by ethylene glycol which was placed in her drink at a party. She almost died and was in the ICU for several days. She lost her hearing and since that time has had a constant, severe headache with ear pressure which is worsening over time. This is so severe I had to resign from my paralegal position to care for her and her child. So far, no medication prescribed by her doctor has helped at all. The only thing that has ever helped are narcotic pain medications, but her doctor does not want to prescribe those for her. She is in bed in pain most of the time. Do you have any suggestions that may help her pain? Thank you.
Doctor Response:
Dear_____,
I am very sorry for the problems your family has endured. I have no expertise on Ethylene Glycol poisoning but I would initially focus on kidney and/or liver damage creating metabolic or electrolyte imbalances resulting in the severe pain. You may want to seek out a medical university with a toxicology program. I would be cautious with drugs until any long term kidney or liver problems have been ruled out.
I would also urge you to look into an Aqualizer appliance. They are inexpensive and could be used as a trial appliance that does not requir a doctor's visit. If the aqualizer gives significant relief than you can investigate neuromuscular dentistry for possible relief.
Dr Ira Shapira
My now 25-year old daughter was poisoned by ethylene glycol which was placed in her drink at a party. She almost died and was in the ICU for several days. She lost her hearing and since that time has had a constant, severe headache with ear pressure which is worsening over time. This is so severe I had to resign from my paralegal position to care for her and her child. So far, no medication prescribed by her doctor has helped at all. The only thing that has ever helped are narcotic pain medications, but her doctor does not want to prescribe those for her. She is in bed in pain most of the time. Do you have any suggestions that may help her pain? Thank you.
Doctor Response:
Dear_____,
I am very sorry for the problems your family has endured. I have no expertise on Ethylene Glycol poisoning but I would initially focus on kidney and/or liver damage creating metabolic or electrolyte imbalances resulting in the severe pain. You may want to seek out a medical university with a toxicology program. I would be cautious with drugs until any long term kidney or liver problems have been ruled out.
I would also urge you to look into an Aqualizer appliance. They are inexpensive and could be used as a trial appliance that does not requir a doctor's visit. If the aqualizer gives significant relief than you can investigate neuromuscular dentistry for possible relief.
Dr Ira Shapira
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