Wednesday, December 29, 2010

What is Neuromuscular Dentistry? I Hate Headaches.org has the answers.

This website is all about utilizing neuromuscular dentistry to treat and prevent migraines and tension type headaches.

I invite you to roam the site and follow the links to learn how the teeth, jaws and jaw muscles along with the trigeminal nerve are partially or completely connected to chronic pain. Neuromuscular dentistry can help a wide variety of chronic pains, treat sleep apnea and snoring, possibly alleviate sympoms of movement disorders including Parkinson's.

Visit Sleep and Health Journal (http://www.sleepandhealth.com/neuromuscular-dentistry) for my detailed article on Neuromuscular Dentistry that was first published by the American Equilibration Society and the republished in ICCMO's annual anthology of Neuromuscular Dentistry.

Learn why TMJ disorders are called The Great Imposter in another Sleep and Health Journal article. http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor

Tuesday, December 28, 2010

Oral Appliances for treating Parkinson's and other movement disorders

The utilization of using Neuromuscular orthotics to treat or eliminate migraines, tension-type headaches and chronic sinus and facial pain is well established. The correction of postural distortion is also well documentd however the treatment of movement disorders has been primarily anectdotal.

That is beginning to change, the correction of oral and pharyngeal reflexes combined into neuromuscular orthotics allows treatment of more complex disorders.

The OSB, or Oral Systemic Balance appliances promoted by Dr Farand Robson are focused into these reflexes. The work of Brendan C Stack DDS MS, Dr John Beck MD and others in treating Parkinsons is exciting new work. The Academy of Craniofacial Pain is a diamond sponsor of this event.

There are two clips on the Parkinson's Resoure organization website dealing with TMJ and Parkinson's and the group has a meeting in January 2011. http://www.parkinsonsresource.org/press/latest-news/item/11-temporomandibular-joint-disorder-and-parkinson’s-breakthrough

Treatment of TMJ disorders (TMD) can have tremendous effects on posture throughout the body. Posturology is a new field of study and TM Joints, jaw position are only two of many factors affecting total posture.

The brain is are central computer, the effect of jaw problems is to create anI/O error or an input /output error. If bad information is fed into the CNS than bad information comes out.

The Natioonal Heart Lung and Blood Institute has excellent information on TMJ disorders and Sleep Apnea at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf in a report CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS NHLBI WORKSHOP

Sunday, December 12, 2010

TENSION-TYPE HEADACHES AND MIGRAINES OFTEN HAVE COMMON CO-MORBIDITIES OF TEMPOROMANDIBULAR DISORDERS, MYOFASCIAL PAIN AND FORWARD HEAD POSITION

A new article "Pure tension-type headache versus tension-type headache in the migraineur." in Curr Pain Headache Rep. 201:465-9.0 Dec;14(6) (PubMed abstract below) looks at primary headache disorders. What is most interesting is that they state that differential diagnosis is made difficult to the frequent presence of co-morbidities including temporomandibular disorders and myofascial pain.

I wish the authors could realize that what they classify as co-morbidities are actually underlying triggers and causes of both migraines and tension-type headaches. When they assume that these headaches are primary they miss the opportunity to actually treat and prevent them from occuring. The authors go on to state "chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache" and missing the fact that central sensitiztion and chronicity is due to not treating the primary trigeminal nerve problem that is secondary to repetitive motion injuries from underlying dysfunction that leads to myofascial pain disorders.

There is a musclar component as well as a neurogenic/vascular component to all headaches. The real issue is the elimination of the conditions that trigger tension-type headaches, migraines and TMJ (TMD) disorders. Neuromuscular dentistry is extremely effective in preventing and eliminating tension-type headaches and migraines because it eliminates the repetitive strain injuries by idealizing the physiologic status of the entire trigeminal nervous system that is responsible in whole or in part for almost all migraines and tension-type headaches as well as other head, neck and facial pain.


Curr Pain Headache Rep. 201:465-9.0 Dec;14(6)
Pure tension-type headache versus tension-type headache in the migraineur.
Blumenfeld A, Schim J, Brower J.
The Headache Center of Southern California, 320 Santa Fe Drive, Encinitas, CA 92024, USA. blumenfeld@neurocenter.com
Abstract
Primary headache disorders include tension-type headache and migraine. These headache types can be differentiated based on strict clinical definitions that depend on the patient's signs and symptoms. However, some of the clinical features can overlap, and in addition, the same comorbid conditions can occur in both headache types. Distinction between these headache types on occasion can be difficult due to comorbid conditions such as temporomandibular joint disorders and myofascial pain with forward head posturing, which may be present in both headache disorders, and thus result in similar features in both conditions. Furthermore, chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache. Finally, in some patients, both tension-type headache and migraine may occur at different times.
PMID: 20878271 [PubMed - in process]

Sunday, December 5, 2010

TMJ disorders and Neck Pain are closely linked. New study shows mechanical and kinematic movement of neck is altered by neck pain.

A recent article (Arch Phys Med Rehabil. 2010 Dec;91(12):1884-90.) showed changes in neck function when pain was present. Neck pain is one of the most frequently helped conditions during neuromuscular treatment of TMD disorders. If treating the pain can return normal function this would be an incredible finding.

The article concludes "Velocity and smoothness of cervical motion were more restricted in patients with chronic neck pain than found previously. Unlike range of motion and other static measurements, these dynamic variables reflect functional cervical motion and therefore contribute to a better understanding of the impairment associated with neck pain. Because the ability to move quickly in response to external stimuli is a commonly occurring phenomenon, this deficit is highly relevant to clinical assessment and management."

The unanswered question is whether the limitation and pain have a common orgin or if the pain is the cause of the changes noted. If the pain alone causes these changes than more debilitating problems would occur over time. An interesting follow-up study would be to examine changes after treatment of pain.

The PPM, Pure Power Mouthguard has been shown to increse flexibility and balance in athletes. A Rutger's study confirmed this. I have frequently seen normalization in pain and function in patients treated with neuromuscular orthotics but these are subjective improvements. This "virtual reality assesment" may be a more objective method to measure improvement in neck function following rehabilatative medicine, physical therapy, chiropractic or osteopathic adjustments and TMD treatment.

Arch Phys Med Rehabil. 2010 Dec;91(12):1884-90.
The effect of neck pain on cervical kinematics, as assessed in a virtual environment.
Bahat HS, Weiss PL, Laufer Y.

Department of Physical Therapy, Faculty of Social Welfare and Health Sciences, University of Haifa, Israel.
Abstract
Sarig Bahat H, Weiss PL, Laufer Y. The effect of neck pain on cervical kinematics, as assessed in a virtual environment.

OBJECTIVE: To compare cervical kinematics during functional motion in patients with neck pain and in asymptomatic participants using a novel virtual reality assessment.

DESIGN: Clinical comparative trial.

SETTING: Participants were recruited from university staff and students, and from a local physical therapy clinic.

PARTICIPANTS: Patients with chronic neck pain (n=25) and asymptomatic participants (n=42).

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Kinematic measures (response time, peak and mean velocity, number of velocity peaks, time to peak velocity percentage) were sampled while participants were engaged in the virtual game. Group and motion direction differences were assessed with a 2-way repeated-measures analysis of variance, Tukey-Kramer testing, and contrast analysis when relevant.

RESULTS: Participants with neck pain had lower peak and mean velocities than the asymptomatic participants (P<.0001). They also demonstrated a greater number of velocity peaks, indicating impaired motion smoothness (P=.0036). No significant group differences were found for response time or for time to peak velocity percentage. Cervical rotations were significantly faster and smoother than flexion and extension movements (P<.05). The overall impairment percentage in velocity and smoothness of cervical motion in patients with neck pain ranged from 22% to 44% compared with asymptomatic participants.

CONCLUSIONS: Velocity and smoothness of cervical motion were more restricted in patients with chronic neck pain than found previously. Unlike range of motion and other static measurements, these dynamic variables reflect functional cervical motion and therefore contribute to a better understanding of the impairment associated with neck pain. Because the ability to move quickly in response to external stimuli is a commonly occurring phenomenon, this deficit is highly relevant to clinical assessment and management.

Copyright © 2010 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
PMID: 21112430 [PubMed - in process]

Thursday, November 25, 2010

WHAT IS THE BEST TMJ TREATMENT?

THERE IS NO SINGLE "BEST TREATMENT" FOR TMJ BECAUSE TMJ IS NO A SINGLE DISEASE OR PROBLEM. TMJ actually stands for TemporoMandibular Joint and it is a joint not a disease. Everyone has two TM Joints. TMD stands for TemporoMandibular Dysfunction but it is also a general term.

The following should help guide patients in finding the "right " doctor.

To receive the "Best TMJ Treatment" it is first necessary to have the "Best TMJ Diagnosis".

The diagnosis is actually the most complex part of treating this group of disorders.

The medical SOAP model is an essential part of arriving at the right diagnosis and treatment and is frequently not followed.

The "S" in SOAP is the subjective findings. These come from the patients history. Many dentists and physicians short change patients by not getting a thorough and complete history. Often, relevant facts about a patient's history are missed or revealed later by patients. I usually set aside a minimum of one hour for a first visit with a patient with chronic pain. My team will often schedule much longer appointments when a case appears complicated. The tentative diagnosis or diagnostic tree (differential diagnosis) is made from the patient's history and interview. It is the confirmed or reevaluated based on Objective findings.

The "O" in SOAP is the objective findings. Before objective testing is done the subjective history helps determine the proper testing that is appropriate for each patient. Objective testing includes Radiographs or x-rays. These may be plain film, cone beam, CT scans, MRI's. These are used to diagnose bony changes and soft tissue changes to the joints.

There are specific objective testing that helps determine the "Best TMJ Treatment" and confirms details of the working diagnosis. Neuromuscular Dentists use the following diagnostic tools to elucidate the complete nature of this disorder.

THE FOLLOWING OBJECTIVE DEVICES ARE USED BY NEUROMUSCULAR DENTISTS TO AID IN DIAGNOSIS AND TREATMENT OF CRANIOMANDIBULAR DISORDERS (TMJ, MPD, MPD,ETC)

EMG or Electromyography that is used to determine starting levels of muscle activity, symmetry of muscle activity, funCtional activity as it relates to posture and function. Spectral Analysis of EMG help to determine underlying physiologic sTatus of the muscles. EMG can also be used to fine tune bite corrections and to measure efficacy of treatment.

Sonography and/or JVA (joint vibration analysis) Can be used to measure the health of the joint and determine thru spectral analysis the amount of joint damage or changes.

MKG (mandibular kinesiograph) , CMS (computerized Mandibular Scans) are used to evaluate function and movement and in conjunction with ULF TENS to measure rest position.

ULF TENS is used diagnostically and as a treatment tool. The the dimensional position of the jaw is evaluated before and after muscle relaxation (as confirmed by EMG)

Blood Tests, urine chemistry, thyroid function are all objective tests that are used when appropriate. Sleep studies are an often under utilized diagnostic tool in finding the "BEST TMJ TREATMENT". Patients with morning headaches, snoring, high blood pressure and excessive daytime sleepiness should always be evaluated with polysomnography. The NHLBI (National Heart Lung and Blood Institute) of the NIH (National Institute of Health) considers Sleep Apnea to be a TMJ disorder.

Psychometric tests are also objective tests that are used in diagnosis. Unfortunately, many doctors believe that there are no real physical ailments and the TMJ is a "psychco-social" disease to be treated with drugs and psychotherapy. There are frequently psycho-social overlays to TMJ problems. Being in chronic pain changes patients in many ways. Psychometric testing often reveals the results of chronic pain rather than the cause.

The "A" in SOAP is the assessment, where all of the subjective and objective information allows the doctor to have a "working diagnosis" and to lay out an initial treatment plan.

The "P" in Soap is the PLAN or methods determined by the Physician or Dentist to be used to treat the patient. This may include use of medications, therapy or diagnostic orthopedic appliances. Many patients need numerous methods of treatment to address the disorders and problems diagnosed and revealed in Subjective and Objective examination. Frequently more than one practitioner will be involved in treatment.


DIAGNOSIS DOES NOT END WHEN A NEUROMUSCULAR DIAGNOSTIC ORTHOTIC IS PLACED IN A PATIENTS MOUTH!

It is essential to understand that diagnosis and treatment is an ongoing procedure and that a SOAP approach is used at subsequent appointments. The "BEST TMJ TREATMENT" is ongoing and as the patients improve it is frequently appropriate for the focus of treatment to change. It is important for the patient and doctor to be open and honest to achieve the best results.

I strongly believe that the Neuromuscular Dentistry approach is the best "TMJ" treatment but it is only a part of the total diagnosis.

Sleep Appliance Causes Patient To Develop "TMJ". Is "TMJ" from Somnomed Sleep Appliance or is sleep apnea a symptom of a TMJ problem?

JEFF: I have an oral device (sonomed) for sleep apnea. It gave me TMJ. I haven't been able to tolerate cpap.


Dr Shapira: YOU STATE THAT YOU HAVE A SOMNOMED TO TREAT SLEEP APNEA BECAUSE YOU CANNOT TOLERATE CPAP.
It is excellent that you have chosen to treat the sleep apnea which can cause heart attacks, strokes, memory loss and excessive daytime sleepiness. Morning Headaches and headaches that wake patients from sleep are usually the result of sleep apnea or TMJ disorders ie "TMD"

YOU THEN STATE THAT YOU DEVELOPED TMJ BUT GAVE NO SPECIFICS AS TO SYMPTOMS. TMJ STANDS FOR TEMPOROMANDIBULAR JOINT, NOT A DISEASE. It is important to understand the SPECIFIC problems so they can be addressed. Patients wearing oral appliances for sleep apnea may experience bite changes or tooth movement but damage should not occur to the joints. It is essential to work with a dentist who has training in treating sleep apnea and TMJ disorders.

I frequently see patients whose bite changes but the feel better. Many of the changes that occur when wearing a sleep appliance are actually due to the body healing. The same developmental problems cause both sleep apnea and TMJ disorders, migraines and chronic daily headaches.

Neuromuscular Dentistry is one of the best approaches to treating headaches and TMJ disorders.

ACCORDING TO THE NHLBI SLEEP APNEA IS A TMJ DISORDER. SEE http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf You have actually developed a new symptom from the same disorder but because you didn't specify symptoms I can not specify what to do next.

The American Academy of Sleep Medicine recommends that dentists treating sleep apnea with oral appliances should be well trained in treating TMJ disorders. I SUGGEST THAT THE BEST QUALIFIED DENTISTS FOR TREATING TMJ DISORDERS ARE NEUROMUSCULAR DENTISTS.

IF YOU CAN GIVE ME SPECIFIC INFORMATION I MAY BE OF MORE HELP. Please review www.ihateheadaches.org to learn about Neuromuscular Treatment of TMJ Disorders, headaches and migraines.

The following is the result of a web form submission from:
comments: I have an oral device (sonomed) for sleep apnea. It gave me TMJ
I haven't been able to tolerate cpap

Monday, November 15, 2010

CENTRAL SENSITIZATION AND TMD: THE CONNECTION TO MYOFASCIAL PAIN, FIBROMYALGIA, HEADACHE, MIGRAINE AND RELATED DISORDERS.

I have frequently discussed the relation between headache, TMD and central sensitization. The trigeminal nerve is a frequent culprit in development of central sensitization which is why neuromuscular dentistry can be such an effective treatment. Decreases in nociceptive input from the trigeminal nerve can allow reversal of a sensitized state.

A new article in Pain "Pain." 2010 Oct 18. "Central sensitization: Implications for the diagnosis and treatment of pain." documents much of what we understand about central sensitization. These heightened central states are caused by noxious or nociceptive input into the brain. The trigeminal nerve carries a tremendous amount of information (nociception) into the CNS.

A recent article "Chronic Orofacial pain" proposes that "we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together." This would be obvious to anyone who evaluates the anatomy and physiology of the brain and especially the stomatognathic system including the jaw muscles, teeth and periodontal ligaments. jaw joints and most importantly the trigeminal nerve. The trigeminal nerve is almost always indicated as a culprit or co-conspirator in chronic and episodic facial pain and headache .

The use of botox on jaw muscles to treat chronic headaches and migraines actually reduces nociceptive input to the trigeminal nerve from and brain from peripheral input. Neuromuscular dentistry also reduces nociceptive input withput the use of toxic nerve agents but utilizing antidromic TENS to relax muscles and establisha healthy physiologic rest position with minimal nociceptive input. Neuromuscular occlusion is simply a physiologic land spot that allows the muscle to return to a health rest position after function.

The computer adage "Garbage in- Garbage out" is what happens when nociceptive input to the brain exceeds our ability to comfortably adapt causing pain and central sensitization. Reduce the "garbage in" with neuromuscula dental techniques and the "garbage out" painful sequellae subside.

Curr Pain Headache Rep. 2010 Feb;14(1):33-40.
Chronic orofacial pain.
Benoliel R, Sharav Y.

Faculty of Dentistry, Department of Oral Medicine, Hebrew University-Hadassah, Jerusalem, Israel. benoliel@cc.huji.ac.il
Abstract
Chronic orofacial pain (COFP) is an umbrella term used to describe painful regional syndromes with a chronic, unremitting pattern. This is a convenience term, similar to chronic daily headaches, but is of clinically questionable significance: syndromes that make up COFP require individually tailored diagnostic approaches and treatment. Herein we describe the three main categories of COFP: musculoskeletal, neurovascular, and neuropathic. For many years, COFP and headache have been looked upon as discrete entities. However, we propose the concept that because COFP and headaches share underlying pathophysiological mechanisms, clinical characteristics, and neurovascular anatomy, they should be classified together.

PMID: 20425212 [PubMed - indexed for MEDLINE]

Cluster Headaches and Sleep Apnea. Cluster Headaches caused by sleep apnea and sleep apnea sequelae may be eliminated with treatment of apnea

All patients with cluster headaches that have onset during sleep should be evaluated for sleep apnea. Sleep apnea causes hypoxia (drop in oxygen) and a rise in CO2. Oxygen therapy is a recognized and effective treatment for sleep apnea. Prevention of many cluster headaches can be addressed by correcting sleep problems.

During apneic events the patients quit breathing oxygen drops followed by hypercapnia or a rise in carbon dioxide levels. This can cause acidosis that could trigger cluster headaches. This leads to an awakening and patients gasping and is associated with adrenaline release or fight or flight reflex. Repetition throughout the night can also be the trigger.

Patients with untreated sleep apnea have abnormal cortisol levels and this disturbs the ability to cope with normal life stresses. There is also an increase in insulin resistance and changes in blood sugar can also be a cluster headache trigger. The article
Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea." from Sleep Res Online. 2000;3(3):107-12 concludes that "in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches."

The National Heart Lung and Blood Institute (NHLBI) considers sleep apnea to be a Temporomandibular Disorder. The NHLBI report "CARDIOVASCULAR AND SLEEP-RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" discusses effects of sleep apnea in detail. Learn more about the dangers of sleep apnea and oral appliance treatment at http://www.ihatecpap.com

A section of the report titled The Craniofacial Complex and its Impact on Control of Upper Airway Resistance and Cardiopulmonary Function- Jaw Biomechanics and Function" discusses sexual dimorphism and may explain why cluster headaches are more common in men. Part of that report follows: "These compartments are activated differently during the production of different oral behaviors, suggesting that they function as output elements used in different combinations by the nervous system. These muscles are complex and unique, containing fibers of phenotypes not found in limb muscles. They are smaller, and express myosin heavy chain isoforms found only in limb muscles during development. The cardiac alpha-myosin heavy chain isoforms of the masseter and temporalis muscles are unique to skeletal muscle and resemble heart muscle. Considerable sexual dimorphism has been identified in these muscles with regard to the slow and fast fibers types of the masseter. Males have predominately fast fiber types while females predominately slow fiber types. These sex differences arise in response to androgens in males but persist even in the absence of androgens."

It is widely accepted that the Trigeminal Nervous system that controls the jaws teeth and associate dental structures is implicated in the majority of all headaches including cluster headache.

Control of the upper airway often decrease or fails during sleep as seen in this excerpt: "Control of Upper Airway Collapsibility During Sleep
The upper pharyngeal airway in humans has relatively little bony or rigid support. Since there is variability in soft tissue and bony structures of the head and neck, there must be mechanisms in place that enable the pharyngeal dilator muscles to adjust for these anatomic differences. Animal and human studies indicate that there are at least three mechanisms to control the activity of the genioglossus muscle. First, negative pressure has substantial impact on this muscle and a clear linear relationship exists between negative pressure in the airway and genioglossal activation. Second, there is pre-motor neuron input to these muscles from respiratory pattern generating circuits as shown by the pre-activation of these muscles that occurs prior to the development of negative pressure in the airway. Third, tonic activity in the muscle is consistently evident, although the mechanisms that determine the level of this activity have not been studied. During sleep, the mechanisms that control upper airway resistance are importantly impacted. Specifically, tonic activity drops markedly and the negative pressure reflex is substantially attenuated or completely lost. These findings have important implications in the pathophysiology of SDB." They probably also have important implications in the physiology and pathology of cluster headaches.

The report also discusses physiological pain processes and central sensitization found in TMJD patients that is similar to findings in cluster and headache patients in this excerpt: "Craniofacial/Deep Tissue Persistent Pain and Relationships to Cardiovascular and Pulmonary Function and Disease.
Injury to peripheral tissues following trauma or surgery often results in hyperalgesia that is characterized by increased sensitivity to painful stimuli. This is a common problem in patients with TMD. Until recently, it was thought that the increase in pain was due to changes at the site of injury but it is now known that it involves central nervous system hyper-excitability leading to long-term changes in the nervous system. Animal models of hyperalgesia produced by inflammation or nerve injury that mimic persistent pain conditions have shown that an increased neuronal barrage into the central nervous system (CNS) leads to central sensitization involving activation of excitatory amino acid transmitters and their receptors. The activation of N-methyl- D-aspartate (NMDA) receptors leads to influx of calcium into neurons, the activation of protein kinases, and phosphorylation of receptors. The net effect of these responses is increased gene expression of NMDA receptors, an alteration in the sensitivity of receptors, increased excitability, and an amplification of pain. These responses appear to be most robust in response to deep tissue injury such as occurs in TMD patients.
Modulation by descending pathways from the CNS importantly influences these events. Under normal conditions, the net effect of the descending neural projections from the brain stem to the spinal cord is to inhibit or counterbalance the hyper-excitability produced by tissue injury. It is now understood that this balance can shift to a net excitatory effect whereby descending modulation results in more hyper-excitability and more pain after injury. This central sensitization appears to be a prominent component in patients suffering from deep pain conditions such as TMD and fibromyalgia. It is believed that the diffuse nature and amplification of pain is in part due to this imbalance and that these findings have important functional implications relevant to the survival of the organism in response to the presence of persistent tissue injury. It is therefore now believed that persistent pain can be attacked both at the site of injury and where it is elaborated in the nervous system."

The report also documents connections with autonomic system derangements that are normally found in headaches, migraines and cluster headaches. These autonomic symptoms are the ones that Sphenopalatine Ganglion Blocks can relieve or eliminate. The relevant section is excerpted below:
" Alteration in Baroreceptor Activity - Impact on Pain, Autonomic Function, Motor Output, and Sleep":

"Evidence has emerged that several regions of the CNS interact in complex ways to integrate sensory perception, autonomic function, motor output, and sleep architecture. The outcomes of a number of recent studies also suggest that several of the signs and symptoms associated with TMD may result, at least in part, from impairments in neural networks that coordinate the interplay between sensory systems, autonomic function, motor output, and sleep architecture. Many of the central pathways that are critically involved with the integration of these systems are regulated by visceral afferent input, including input from cardiopulmonary, carotid sinus, and aortic arch baroreceptors. In addition, abnormalities in the function and central integration of baroreceptor afferent information has been associated with abnormalities in pain perception, autonomic function, motor output, and sleep architecture, and thus may contribute to the development and maintenance of TMD and other related disorders (e.g., fibromyalgia). There is a need for additional studies that systematically examine whether abnormal baroreceptor function contributes to the pathogenesis of TMD."

Several relevant studies on TMD and Sleep Apnea are included below:

Cranio. 1997 Jan;15(1):89-93.
Cluster-like signs and symptoms respond to myofascial/craniomandibular treatment: a report of two cases.
Vargo CP, Hickman DM.

Raleigh Regional Center for Head, Neck and Facial Pain in Beckley, West Virginia, Morgantown, USA.
Abstract
Two cases with pain profiles characteristic of cluster-like headache, both within and outside the trigeminal system, are reported. One male patient would typically awaken from sleep with severe unilateral temporal head pain and autonomic signs of ipsilateral lacrimation and nasal congestion. A female patient exhibited severe unilateral boring temporal and suboccipital head pain with associated ipsilateral lacrimation and rhinorrhea. In addition, both patients presented with signs and symptoms of masticatory and/or cervical disorders. These two cases illustrate possible treatment alternatives, as well as possible influences from cervical and masticatory structures in the development of cluster or cluster-like headache.

PMID: 9586493 [PubMed - indexed for MEDLINE]

Cranio. 1995 Jul;13(3):177-81.
Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.
Peterson JN, Schames J, Schames M, King E.

Headache and Pain Center, Hollywood Community Hospital, Los Angeles, CA 90028, USA.
Abstract
The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.

PMID: 8949858 [PubMed - indexed for MEDLINE]



Ned Tijdschr Tandheelkd. 2006 Nov;113(11):474-7.
[Spontaneous pain attacks: neuralgic pain]
[Article in Dutch]

de Bont LG.

Universitair Medisch Centrum, Groningen. l.g.m.de.bont@kchir.umcg.nl
Abstract
Paroxysmal orofacial pains can cause diagnostic problems, especially when different clinical pictures occur simultaneously. Pain due to pulpitis, for example, may show the same characteristics as pain due to trigeminal neuralgia would. Moreover, the trigger point of trigeminal neuralgia can either be located in a healthy tooth or in the temporomandibular joint. Neuralgic pain is distinguished into trigeminal neuralgia, glossopharyngeal neuralgia, Horton's neuralgia, cluster headache and paroxysmal hemicrania. In 2 cases trigeminal neuralgia is successfully managed with a neurosurgical microvascular decompression procedure according to Jannetta. Characteristic pain attacks resembling neuralgic pain result from well understood pathophysiological mechanisms. Consequently, adequate therapy, such as a Janetta procedure and specific pharmacological therapy, is available.

PMID: 17147031 [PubMed - indexed for MEDLINE]


Sleep Res Online. 2000;3(3):107-12.
Timing patterns of cluster headaches and association with symptoms of obstructive sleep apnea.
Chervin RD, Zallek SN, Lin X, Hall JM, Sharma N, Hedger KM.

Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Harbor, Michigan, USA. chervin@umich.edu
Abstract
Cluster headaches (CH) frequently recur at the same point in the circadian cycle, often during sleep. They may, in some cases, represent a susceptible individual's response to hypoxemia or other physiological changes induced by obstructive sleep apnea (OSA). If and when this mechanism exists, timing of CH close to the onset of sleep-and therefore OSA-might be expected. We questioned 36 subjects with CH about the times at which their CH usually occurred and about several symptoms known to be predictive of OSA, including habitual snoring, loud snoring, observed apneas and excessive daytime sleepiness. We then used logistic regression to determine whether occurrence of CH in each of six time periods was associated with OSA symptoms. The 23 subjects (64%) who reported CH in the first half of a typical night's sleep also tended to report headaches during the midday/afternoon period. Symptoms of OSA, and in particular habitual snoring, were predictive of both first-half-of-the-night and midday/afternoon CH (p<.05). Thirty-one subjects (86%) reported that their CH were sleep-related, usually occurring during any part of the night or on awakening, but symptoms of OSA were not predictive of this timing pattern. In short, several OSA symptoms showed an association with CH occurrence in the first half of the night but not with sleep-related CH in general. These findings suggest that in some patients, physiological consequences of OSA may trigger CH during the first few hours of sleep and thereby influence the timing of subsequent daytime headaches.

PMID: 11382908 [PubMed - indexed for MEDLINE]

Sunday, November 7, 2010

Facial Pain, Normal Sinus CT scans, Headache, Migraine and TMD

An older study in the Laryngescope is on 104 patients with facial pain who had normal CT scans. Twenty nine of the patients had previous unsuccessful sinus surgery. The patients were approximately 80% women, TMJ disorders are usually (80%) found in female patients.

The study showed " Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis." It is essential that organic neurologic causes are ruled out but the 100 remaining patients had headaches of undetermined causes. Facial pain and sinus pain are a alert for MPD (myofascial pain) and TMD (temporomandibular pain). Treatment of patients with chronic headaches, migraines sinus and/or facial pain is frequently done without a neuromuscular dental evaluation even though NMD has extremely high success rates.

The Trigeminal nerve innervates the sinus cavities. It is often called the Dentist's nerve because the trigeminal nerve primarily goes to the teeth, jaw muscles, jaw joints, periodontal ligaments and is responsible in full or part for most headaches. It also controls blood flow to the anterior 2/3 of the brain thru the meninges.

Correction of underlying neuromuscular problems often allows drug free effective treatment. When CT scans are normal patients with sinus pain and facial pain should always be evaluated by a neuromuscular dentist. Neurologists should evaluate all patients with organic brain disorders but functional treatment is preferred to heavy drug therapy for the majority of patients.

Frequently Chiropracters and dentists can get miraculous results by working together especially NUCCA and A/O (Atlas Orthogonal) chiropracters. The Dentists can correct nociceptive trigeminal nerve input while the chiropracters correct cervical and head posture. Long term correction of those problems usually requires correction of descending conditions associated with improper jaw function.



Laryngoscope. 2004 Nov;114(11):1992-6.
Neurologic diagnosis and treatment in patients with computed tomography and nasal endoscopy negative facial pain.
Paulson EP, Graham SM.

Department of Otolaryngology--Head and Neck Surgery, University of Iowa, Iowa City, Iowa 52242-1093, USA.
Abstract
OBJECTIVE: To determine the helpfulness of specialist neurology referral for patients with facial pain, a normal sinus computed tomography (CT) scan, and normal nasal endoscopy findings.

STUDY DESIGN: Prospective identification of patients and analysis of data approved by the Institutional Review Board.

METHODS: The data of 104 consecutive patients presenting with facial pain, a normal sinus CT scan, and normal nasal endoscopy findings were reviewed. The patients presented to a single rhinologist in a tertiary care institution. All patients were referred for specialist neurologic evaluation and potential treatment. Further information was obtained from a patient survey.

RESULTS: Of the 104 patients, 81 were women and 23 were men. The average age was 46 years (range, 22-85). Fifty-six had clear CT scans, 48 had minimal change, and all had negative endoscopies. Twenty-nine had previous unsuccessful sinus surgery. The average follow-up period was 10.5 months. Forty of 75 patients seeing a neurologist were seen on multiple occasions. Four percent of patients seen by a neurologist had an unsuspected serious intracranial diagnosis. The most common diagnoses were migraine (37%), rebound headache (17%), chronic daily headache (17%), and obstructive sleep apnea (16%). Overall, 58% improved on medical therapy; 60% of those with a clear CT scan improved, and 53% of those with minimal change on CT scan improved (P = .749).

CONCLUSIONS: Facial pain remains a difficult symptom to diagnose and treat in rhinologic practice. Patients often undergo surgery without help. Most patients with facial pain, a normal sinus CT scan, and normal endoscopy findings benefit from neurologic consultation. Serious intracranial pathologic conditions can be excluded and diagnosis-specific pharmacogenetic therapy instituted with improvement in more than 50%.

PMID: 15510029 [PubMed - indexed for MEDLINE]

Saturday, October 2, 2010

HEADACHES, MIGRAINES, FIBROMYALGIA, SLEEP APNEA, SWALLOWING PROBLEMS AND TMJ DISORDERS ARE ALL CLOSELY RELATED IN BOTH CAUSES AND TREATMENTS

PLEASE READ THIS ENTIRE BLOG ENTRY TO UNDERSTAND THE RELATIONSHIPS OF THESE DISORDERS. ALMOST ALL TREATMENT OF HEADACHES MUST CONSIDER THE MASTICATORY SYSTEM.

A new study "Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms." (see abstract below) suggests that treatment of sleep apnea will aid in resolution of symptoms. While this study used CPAP, Oral Appliances should have identical results.

The study concludes that "The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

Another study "Obstructive sleep apnea and depression." (see abstract below) reports 21-41% depression in sleep pne patients. It sites a previous study that lists sleep apnea as a risk factor for depression. It is not surprising that " Patients who have depression as well as OSA appear worse off than those with OSA only" ties together symptoms and treatments of sleep apnea, headaches and depression.

An opinion statement in Curr Treat Options Neurol. 2010 Jan;12(1):1-15 on on "SLEEP AND HEADACHES" ties together headaches, psychiatric problems and sleep apnea but stops short of what the NHLBI report that focuses on masticatory/trigeminal orgin of these problems.

The NHLBI published a report on the "CARDIOVASCULAR AND SLEEP RELATED CONSEQUENCES OF TEMPOROMANDIBULAR DISORDERS" THAT LOOKS AT MASTICATORY SYSTEM AS A COMMON CAUSE OF SLEEP APNEA, HEADACHES AND MANY OTHER PROBLEMS. Shimshak et al published two articles in Cranio that showed a 200-300% increase in medical costs in every field of medicine in patients diagnosed with TMJ disorders. This would include headache, migraine, depression and other diverse conditions.

The National Heart Lung and Blood Institue report states:
"The term TMD refers to a collection of medical and dental conditions affecting the temporomandibular joint (TMJ) and/or muscles of mastication, as well as contiguous tissue components. Symptoms range from occasional discomfort to debilitating pain and severely compromised jaw function. The masticatory apparatus is not only involved in chewing and swallowing but also in other critical tasks, including breathing and talking. Specific etiologies such as trauma and degenerative arthritides underlie some forms of TMD but there is no common etiology or biological explanation. TMD is hence comprised of a heterogeneous group of health problems whose signs and symptoms are overlapping but not identical.
Although broad longitudinal and cross-sectional epidemiological studies have not been carried out, TMD is estimated to affect about 12% of the general population, representing more than 34 million Americans. The majority of those seeking treatment are women in their reproductive years. As for many other pain conditions, the clinical scenario of TMD also tends to be more severe in women than men. TM disorders are considered a serious health problem because many individuals lose their ability to hold regular jobs and to function productively even within the context of a household environment.

The report talks about symptoms including "TMD has been used to characterize a wide range of conditions diversely presented as pain in the face or jaw joint area, masticatory muscle pain, headaches, earaches, dizziness, limited mouth opening due to soft or hard tissue obstruction, TMJ clicking or popping sounds, excessive tooth wear and other complaints."

The report also discusses effects on swallowing and breating ease: "There appears to an associated increase in coughing in subjects with sleep apnea. Occlusion of the pharynx can force residual secretions into the glottis and trigger coughing reflexes, swallowing reflexes, and other reflexes that could contribute to the disorganization of breathing during sleep. In addition to the muscles of mastication, the tongue plays an important role in the coordinated events of swallowing and breathing. The integration of breathing and swallowing is tightly linked, and these events in turn are in some manner linked to blood pressure regulation. Each of these pathways has been studied by scientists in individual disciplines, but there is a need for interdisciplinary studies to determine the interactions of the peripheral and central neural pathways controlling breathing, chewing, swallowing, and cardiovascular events. The presence of pain in patients with TMD would be expected to seriously impact upon these reflex and motor pathways. Little is known about the role of tongue position and how this may be altered in subjects with altered jaw location and structure. Sleep state has been shown to alter the central modulation of the coordination of breathing, airway dynamics, swallowing, and associated cardiovascular events. Differences in central modulation of these events in subjects with sleep apnea and TMD need to be evaluated using sleep as a dynamic change in the state of the individual. Cardiovascular, neuroendocrine, respiratory and swallowing alterations in awake and sleeping subjects need to be studied in a systematic manner in both in animal models and human subjects."

There are common developmental aspects that have been well documented between sleep apnea and TMJ disorders. There is an enormous cross over of signs and symptoms as well. While all sleep apnea may not be entirely related to masticatory structures there is unquestionably a large amount of crossover. There is a solid base of evidence based studies showing how airway issues change growth and development. There is also solid evidence based studies on treatment of sleep apnea with appliances that anteriorly position the mandible. there are numerous clinical reports and studies showing treatment of headaches and TMJ disorders with anterior positiong.

Is it time to look at a large proportion of sleep apnea as being related to jaw development. This would make it a treatment that could be treated and corrected by early interventions such as tonsilectomy and maxillary expansion. Maxillary expansion allows the mandible to automatically anteriorly position and frequently grow a healthier airway. A recent study showed that most pediatric patients having tonsils removed should also have expansion. Expansion according to many experts should precede tonsilectomy to reduce post operative risks.

The early correction of airway and jaw disorders could possibly save massive dollars in lifetime medical expenses if we extrapolate from the work of Shimshak. Shimshak did not show a correlation not cause and effect of TMJ disorders to increased medical expenses.

My opinion is that there is a definite cause and effect of TMJ disorders to massive increases in medical expenses. I believe that for the majority of patients sleep apnea are due to masticatory conditions that should be defined as a TMJ disorder. If we define sleep apnea as a TMJ disorder that other problems like ADD and ADHD are secondary TMJ disorders. This would also apply to morning headaches, cardiovascular, neurological, and psychiatric disorders


Sleep Med. 2010 Jun;11(6):552-7. Epub 2010 May 21.
Effect of CPAP treatment on residual depressive symptoms in patients with major depression and coexisting sleep apnea: Contribution of daytime sleepiness to residual depressive symptoms.
Habukawa M, Uchimura N, Kakuma T, Yamamoto K, Ogi K, Hiejima H, Tomimatsu K, Matsuyama S.

Department of Neuropsychiatry, Kurume University School of Medicine, Kurume, Fukuoka, Japan. hmitsu@med.kurume-u.ac.jp
Abstract
BACKGROUND: Although extensive studies have indicated a relationship between obstructive sleep apnea (OSA) and depressive symptoms, the effect of continuous positive airway pressure (CPAP) treatment on residual depressive symptoms in patients with both major depressive disorder (MDD) and coexisting OSA has not been examined.

METHODS: Seventeen patients with continued MDD despite pharmacotherapy such as antidepressants and/or benzodiazepines, who also had comorbid OSA, were required to complete the Beck Depression Inventory (BDI), Hamilton Rating Scale for Depression (HRSD), and Epworth sleepiness scale (ESS) at the commencement of the study and then again after 2 months of CPAP treatment.

RESULTS: BDI and HRSD scores decreased from 19.7 to 10.8 and 16.7 to 8.0 after 2 months of CPAP treatment (both p<0.01). We also found significant correlations among the improvement rates in BDI, HRSD and ESS scores (R=0.86 and 0.75, both p<0.01). The mixed effect model demonstrated a significant ESS effect on BDI and HRSD.

CONCLUSIONS: The results suggest that MDD patients with residual depressive symptoms despite pharmacotherapy who also have symptoms of suspected OSA, such as loud snoring, obesity, and daytime sleepiness, should be evaluated for sleep apnea by polysomnography and treated with an appropriate treatment such as CPAP. CPAP treatment may result in a significant improvement of residual depressive symptoms due to the improvement of daytime sleepiness in these patients.

PMID: 20488748 [PubMed - indexed for MEDLINE]

Sleep Med Rev. 2009 Dec;13(6):437-44. Epub 2009 Jul 10.
Obstructive sleep apnea and depression.
Harris M, Glozier N, Ratnavadivel R, Grunstein RR.

Australasian Sleep Trials Network, Adelaide Institute for Sleep Health, Flinders University, Adelaide, Australia. melanie.harris@flinders.edu.au
Abstract
There are high rates of depression in people with obstructive sleep apnea (OSA) in both community and clinical populations. A large community study reported a rate of 17% and reports for sleep clinic samples range between 21% and 41%. A large cohort study found OSA to be a risk factor for depression, but we are unaware of any longitudinal study of the reverse association. However correlations have not generally been found in smaller studies. Well-designed longitudinal studies are needed to examine temporal relationships between the two conditions and further research is needed to establish the role of confounders, and effect modifiers such as gender, in any apparent relationship. Symptoms common to OSA and depression, such as sleepiness and fatigue, are obstacles to determining the presence and severity of one condition in the presence of the other, in research and clinically. Sleep clinicians are advised to consider depression as a likely cause of sleepiness and fatigue. Several possible causal mechanisms linking OSA and depression have been proposed but not established. Patients who have depression as well as OSA appear worse off than those with OSA only, and depressive symptoms persist in at least some patients in short term studies of treatment for OSA. Direct treatment of depression in OSA might improve acceptance of therapy, reduce sleepiness and fatigue and improve quality of life, but intervention trials are required to answer this question.

PMID: 19596599 [PubMed - indexed for MEDLINE]

Curr Treat Options Neurol. 2010 Jan;12(1):1-15.
Sleep and headache.
Rains JC, Poceta JS.

Center for Sleep Evaluation, Elliot Hospital, One Elliot Way, Manchester, NH, 03103, USA, jrains@elliot-hs.org.
Abstract
OPINION STATEMENT: Headache has been linked to a wide range of sleep disorders that may impact headache management. There are no evidence-based guidelines, but the authors believe that literature supports the following clinical recommendations: 1. Diagnose headache according to standardized criteria. Specific diagnoses are associated with increased risk for specific sleep and psychiatric disorders. 2. Collect sleep history in relation to headache patterns. Screening questionnaires and prediction equations are cost-effective. 3. Rule out sleep apnea headache in patients with awakening headache or higher-risk headache diagnoses (cluster, hypnic, chronic migraine, and chronic tension-type headache); patients with signs and symptoms of obstructive sleep apnea warrant polysomnography and treatment according to sleep medicine practice guidelines. There is no evidence for suspending conventional headache treatment in suspected or confirmed cases of sleep apnea. Treatment of sleep apnea with CPAP may improve or resolve headache in a subset of patients. The impact on sleep apnea headache of other treatments for sleep apnea (eg, oral appliances, surgery, weight loss) is largely untested. At a minimum, sedative-hypnotic drugs should be avoided in suspected apneics until the sleep apnea is treated. 4. Among patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients. Patients who suffer from chronic migraine or tension-type headache may benefit from behavioral sleep modification. Pharmacologic treatment may be considered on a case-by-case basis, with hypnotics, anxiolytics, or sedating antidepressants used to manage insomnia, tailoring treatment to the symptom pattern. 5. Individuals with chronic headache are at increased risk for psychiatric disorders. Assessment for depression and anxiety may be warranted when either insomnia or hypersomnia is present. Psychiatric symptoms affect the choice of sedating versus alerting versus neutral pharmacologic agents for headache. 6. All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management.

Wednesday, September 29, 2010

Sphenopalatine block and tinnitus,swallowing problems and other disorders

I just had a patient in the office who we did a spenopaltine block on 1 week ago with major relief of shoulder pain (I was not treating) and reduction of tinnitus and droopy eyelids that we were sleeping. My patients chief complaint is swallowing problems that were better almost immediately after the SPG block

I have seen patients with severe insomnia sleep well without medications, other patients who have had relief from restless leg and other diverse conditions.

I usually do SPG blocks for sinus pain and pressure, migraine prevention or treating cluster headaches. However, when patients have "wierd" symptoms it is nice to have the SPG block as a possible treatment.

The Sphenopalatine ganglion is an autnomic nervous center and if we see only temporary relief frow symptoms it is possible to send patients to a neurologist for a stellate ganglion block for longer lasting relief.

Headaches since June, Back of head that last 1 1/2 days and end with throwing up.

Rachel: I have on going headaches since June. They are in the back area of the head and I usually have them for 1 day and half. Most of the time I end up throwing up

Dr Shapira response: Dear Rachel,

I assume that you have visited you physician to discuss your headaches due to the dramatic change. If nothing is found medically occipital headaches are frequently helped by a neuromuscular orthotic. Symptoms that you describe can also be caused by Atlas/Axis problems and you might want to consider seeing an Atlas Orthogonal or NUCCA chiropracter..

If the pain is primarily muscle ait may be easy to relieve utilizing Travell vapocoolant spray and stretch. Does the pain go away immediately after vomiting? When you vomit it causes instant but temporary release of closing jaw muscles.

It is always important to consider organic disease when a new type of headache occurs. Never assume that there is not an undrlying disease process. Neuromuscular Dentistry is probably one of the safest and most effective treatments for chronic headaches and migraines but when a new type of headache occurs it is important to rule out other medical causes.

Objective diagnosis is the key, you do not want to become a drug guinea pig diagnosed by serial drug experiments.

One in Six patients perceive that wrong diagnosis have been made.

An interesting study from the Archives of Internal Medicine (abstract below)reports that 1one in six patients percieve that their doctors have made wrong diagnosis. The study reported "Patients with chronic back pain, higher educational attainment, and poor physical health were at increased odds of perceiving mistakes".

This leads to two questions, were there actual mistakes in diagnosis and treatment or was this just a patient perception. Is it possible that there were multiple diagnosis and they were not yet all discovered?

I frequently see Headache and Migraine patients with numerous diagnosis and medications. I treat these patients with neuromuscular dentistry and their pain is rapidly eliminated. This does not mean that the previous diagnosis were wrong but rather treatment was ineffective. Typically patients with TMJ problems that lead to headaches have seen a minimal of six doctors prior to seeing the dentist, sometimes dozens of physicians. That is why TMJ Disorders are called "THE GREAT IMPOSTER" SEE http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor to read "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER"

Elimination of the headaches does not necessarily mean that other diagnosis were wrong but rather they were not the true cause of the pain. The expression "you can't see the forest for the trees" describes this type of problem. Relieving the headaches and Neuromuscular symptoms makes the patients feel great but frequently remaining symptoms not related to the Trigeminal Nervous system can also be discovered.

Dr Mercola of Mercola.com stated "One in Six Patients Report Getting Wrong Diagnosis
With each survey, study, and statistical review, the answer remains the same: Patients beware, because conventional medicine may inadvertently lead to you or your family's premature demise." It is important to note that this study was talking about patient perceptions about their diagnosis not actual diagnosis.

Solving chronic pain problems is like peeling an onion, as you relieve one layer of the onion you come to the next. Different layers of the onion may need different practioners or treatment. Sometimes it is necessary to treat one problem before progress can be made in other problems.

I frequently see patients who also go to chiropracters or osteopaths for spine adjustments that relieve their headaches but the adjustments do not hold. Combining a diagnostic neuromuscular orthotic with the chiropractic treatment eliminates the trigeminal system problems but also allows the spine to stabilize. Neither treatment works as well alone as the two treatment work combined.

I once had a patient who had constant daily headaches that were completely relieved by a neuromuscular orthotic with the exception of a pain in the right occipital area. The patient stated that was the first pain when the problem started, but did not remember that until the rest of the pain was gone. I could not find any trigger points in the muscle to duplicate the pain but the patient said that he first experienced the pain while playing golf and taking a back swing. When we had him repeat that motion the trigger point became active and we could locate, inject and eliminate it with complete relief of years of pain. That was probably the original injury but would never have been found without first getting him off of medications that masked the pain, correcting occlusal problems (TMD not TMJ this patient had no TM Joint problems just neuromuscular problems)

This patient had had several cat scans and an MRI and was told he has Multiple Sclerosis due to an abnormal MRI and symptoms. He refused to return to the neurologist but I explained that the MRI changes were real. When he revisted a new neurologist the MRI was still abnormal but because there were no symptoms no diagnosis of MS was made. The neurologist did say it could be a problem in the future but for many years the pain did not return. This case is one where the symptoms plus the abnormal MRI combined were used for the diagnosis but taken seperately a very different outcome. If there had never been pain the MRI would not have been taken and the accidental discovery of a questionable area on the brain would not be seen"

The study mentioned patients with back pain. Radiographic imaging of a patient with back pain frequently shows abnormalities which the pain is the attributed to. Patient with these same abnormalities are walking around pain free for years but no imaging is ever done until the pain occurs. Finding pain and radiographic changes does not always imply cause and effect. Studies have shown that the bell curves of pain and bell curves of radigraphic changes are not the same. Some patients with terrible arthritis have no pain and some with miserable pain have little objective evidence of pain. When the pain is labeled frequently other causes of pain are no longer even considered. The diagnosis of arthritis is correct but is just not the cause of pain. Arch Intern Med. 2010 Sep 13;170(16):1480-7.

Patient perceptions of mistakes in ambulatory care.

Kistler CE, Walter LC, Mitchell CM, Sloane PD.
Division of Geriatrics, Department of Medicin, University of California-San Francisco, USA. umanohone@yahoo.com
Arch Intern Med. 2010 Sep 13;170(16):1487-9.
Abstract
BACKGROUND: Little information exists about current patient perceptions of medical mistakes in ambulatory care within a diverse population. We aimed to learn about the perceptions of medical mistakes, what factors were associated with perceived mistakes, and whether the participants changed physicians because of these perceived mistakes.

METHODS: We conducted a cross-sectional survey at 7 primary care practices in North Carolina of English- or Spanish-speaking adults, aged 18 years and older, who saw a health care professional during 2008. Main outcome measures were 4 questions about patient perceptions of medical mistakes in the ambulatory care setting, including (1) overall experience with a medical mistake; type of mistake, such as a (2) diagnostic mistake or (3) treatment mistake, and its associated harm; and (4) effect of this mistake on changing physicians.

RESULTS: Of 1697 participants, 265 (15.6%) responded that a physician had made a mistake, 227 (13.4%) reported a wrong diagnosis, 212 (12.5%) reported a wrong treatment, and 239 (14.1%) reported having changed physicians because of a mistake. Participants perceived mistakes and harm in both diagnostic care and medical treatment. Patients with chronic back pain, higher educational attainment, and poor physical health were at increased odds of perceiving mistakes, whereas African American patients were less likely to perceive mistakes.

CONCLUSIONS: Patients perceived mistakes in their diagnostic and treatment care in the ambulatory setting. These perceptions had a concrete effect on the physician-patient relationship, often leading patients to seek another health care professional.

PMID: 20837835 [PubMed - in process]

Monday, September 27, 2010

Chronic daily headaches and meds don't work. What should I do? Neuromuscular Dentistry may be the answer.

Chronic headaches without a cause are frequently related to the Trigeminal nervous system and have no specific diagnosis. When headaches are not helped by routine medical care a neuromuscular dentist may be the best answer.

Question from Tiffany: I have been having headaches everyday now for about a year and 9 months now. Had no accidents or head trama btu i have headaches everyday ..No meds work for me only excedrin for about an hours and the head aches is right back. I really dont know the cause but i would like to find out more or what could be causing this.

Dr Shapira Response.

Tiffany, chronic headaches are usually coming from head and neck musculature, especially those muscle innervated by the Trigeminal Nerve. There may or may not be any joint noise or discomfort. A thorough medical evaluation with your physician to rule out organic disease is alway in order.

I start patients with a consultation appointment and usually can relieve a significant amount of pain during the appointment. Most muscle pains can be allieviated or eliminated temporarily with vapocoolant spray and stretch techniques to confirm muscle problems.
I start treatment with a thorough head and neck exam and a neuromuscular dental work up and than a neuromuscular diagnostic orthotic. Most patients see drastic improvement in just a couple of visits. There are no magic cures and it takes time for a chronic problem to unwind completely.

Sunday, September 26, 2010

IF NEUROMUSCULAR DENTISTRY IS SO EFFECTIVE IN TREATING TENSION TYPE HEADACHES AND MIGRAINES WHY DON'T MORE PHYSICIANS REFER PATIENTS TO DENTISTS.

THE ANSWER TO THIS HAS TO DO WITH HOW PHYSICIANS ARE GENERALLY TRAINED AND THE FACT THEY ARE COMFORTABLE REFERRING TO OTHER PHYSICIANS. DENTISTS ARE USUALLY OUTSIDE THE TYPICAL REFERRAL PATTERNS FOR PHYSICIANS.

A SECOND REASON IS MANAGED CARE. PHYSICIANS ARE FREQUENTLY FINANCIALLY RESPONSIBLE FOR COSTS OF REFERRALS THEY MAKE AND DO NOT WANT TO BE STUCK WITH A LARGE BILL (OR DECREASE IN PAYMENTS).

MANY YEARS AGO I WORKED WITH CHICAGO HMO AND SHOWED THEM I COULD SAVE THEM SUBSTANTIAL AMOUNTS OF MONEY IN TREATING CHRONIC PAIN PATIENTS. AS A RESULT THEY GAVE ME A PREFERRED STATUS WHERE THERE WAS LITTLE OUT OF POCKET COST FOR THE PHYSICIANS WHEN REFERRING PATIENTS FOR TMJ THERAPY. DR TRUBITT WHO WAS THE MEDICAL DIRECTOR OF CHICAGO HMO SAID THAT THE COMPANY SAVED APPROXIMATELY $250.000 IN THE FIRST 6 PATIENTS WE TREATED (TOTAL COST ABOUT $25,000). CHICAGO HMO PAID 100% OF ALL MY TMD TREATMENT COSTS (PHASE 1) FOR SEVERAL YEARS BECAUSE THEY SAVED MONEY ON EVERY PATIENT TREATED. THE PATIENTS GAVE THE INSURANCE COMPANY VERY POSITIVE FEEDBACK. CHICAGO HMO DID NOT COVER PHASE 2 TREATEMNT SO PATIENTS WERE MADE AN APPLIANCE WITH A CAST BASE. PATIENTS DESIRING ORTHODONTICS OR RECONSTRUCTION DID SO AS AN OUT OF POCKET EXPENSE.

I WAS REFERRED PATIENTS FOR MANY YEARS WITH GREAT SUCCESS UNTIL CHICAGO HMO WAS BOUGHT BY ANOTHER COMPANY. THE NEW COMPANY WAS NOT INTERESTED IN LEARNING HOW THEY COULD SAVE MONEY. THEY DID WRITE CONTRACT LANGUAGE SAYING THAT TMJ DISORDERS WERE NOT COVERED.

THE EXPRESSION IS PENNY WISE AND POUND FOOLISH. TWO STUDIES PUBLISHED IN CRANIO BY SHIMSHAK ET AL SHOWED THAT PATIENTS WITH TMJ DISORDERS USE MEDICAL CARE IN ALL FIELDS OF MEDICINE AT 200-300% INCREASES ABOVE NON-TMJD PATIENTS. THE TOTAL MEDICAL SAVINGS DWARF THE COST OF TREATMENT BUT INSURANCE COMPANIES ONLY LOOKED AT THE COSTS NOT THE FUTURE SAVINGS.

QUALITY OF LIFE IS NEVER LOOKED AT BY INSURANCE COMPANIES IN THEIR CALCULATIONS.

THE SAME PROBLEM EXISTS IN TREATMENT OF SLEEP APNEA WHERE PATIENTS ARE ROUTINELY REFERRED FOR CPAP EVEN THOUGH 60% OF PATIENTS ABANDON IT COMPLETELY. ALMOST ALL STUDIES SHOW PATIENTS PREFER ORAL APPLIANCES TO CPAP.

THIS IS ALSO TRUE IN TREATMENT OF GUM DISEASE THAT CREATES CARDIAC PROBLEMS, DIABETES PROBLEMS, INCREASES IN PULMONARY INFECTIONS, PREMATURE BIRTH AND OTHER CONDITIONS BUT MOST PHYSICIANS KNOW LITTLE TO NOTHING ABOUT ORAL HEALTH AND ITS EFFECT ON OVERALL HEALTH. MOST MEDICAL INSURANCE COMPANIES DO NOT COVER THE COST OF TREATING PERIODONTAL DISEASE.

PATIENTS IN CHICAGOLAND AREA CAN CONTACT ME ABOUT TMJ DISORDERS AT 1-800-TM-JOINT AND ABOUT ORAL APPLIANCES FOR TREATING SLEEP APNEA AT 1-8-NO-PAP-MASK.

Friday, September 24, 2010

Trigger point injections are an essential part of TMD, Migraine and Headache treatment for many patients

The importance of this study though extremely limited is that it explains why understanding Myofascial Pain and Dysfunction is essential when chronic pain problems including neck pain, headache and TMD disorders. In this study a single injection in the trapezius muscle (shoulder) gave significant reduction in pain in the masseter region along with reduction in EMG values.

There are hundreds of trigger point areas. It is essential to see a physiian or dentist who understands Myofascial Pain and knows how to preform trigger point injections as well as trigger point deactivation with vapocoolants.

Treating patients with drugs and not addressing underlying causes of pain is like painting your ceiling every time it rains instead of fixing where your roof leaks. Neuromuscular Dentistry is used to create a healthy environment where trigger points do not return.

Pain. 1993 Dec;55(3):397-400.
Reduction of pain and EMG activity in the masseter region by trapezius trigger point injection.
Carlson CR, Okeson JP, Falace DA, Nitz AJ, Lindroth JE.

Department of Psychology, College of Dentistry, University of Kentucky, Lexington 40536.
Abstract
In this open, uncontrolled trial, 20 patients with upper trapezius muscle trigger point pain and ipsilateral masseter muscle pain received a single trigger point injection of 2% lidocaine solution (without epinephrine) in the upper trapezius muscle. Following the trapezius injection, there was a significant (P < 0.001) reduction in pain intensity ratings for pain in the masseter region. In addition, there was a significant (P < 0.03) reduction in EMG activity in the masseter muscle. Overall, however, a significant relationship between EMG activity in the masseter and the self-report of pain was not found with the present data set. These clinical findings support the contention that sources of deep pain can produce heterotopic sensory and motor changes in distant anatomical regions.

PMID: 8121703 [PubMed - indexed for MEDLINE]

Mandibular advancement, nasal breathing and swallowing.

Swallowing disorders are frequently associated with TMJ disorders. Abnormal breathing patterns are also associated with both TMJ disorders and Sleep apnea and snoring. This new study "The mandible advancement may alter the coordination between breathing and the non-nutritive swallowing reflex." in the Journal of Oral Rehabilitation (see abstract below) concludes "that mandible re-positioning may strongly influence the coordination between nasal breathing and non-nutritive swallowing by altering respiratory parameters and by inhibiting movement of the tongue-jaw complex.

This inhibition of movement may be a partial explanation of why anterior positioning appliances help muscle problems. The patients may just be breathing easier in this new position. It is another example of convergence between TMD and Sleep Apnea

J Oral Rehabil. 2010 May 1;37(5):336-45. Epub 2010 Mar 10.
The mandible advancement may alter the coordination between breathing and the non-nutritive swallowing reflex.
Ayuse T, Ayuse T, Ishitobi S, Yoshida H, Nogami T, Kurata S, Hoshino Y, Oi K.

Department of Special Care Dentistry, Nagasaki University Hospital, Nagasaki, Japan.
Abstract
The coordination between nasal breathing and non-nutritive swallowing serves as a protective reflex against potentially asphyxiating material, i.e. saliva and secretions, entering the respiratory tract. Although this protective reflex is influenced by positional changes in the head and body, the effect of mandible position on this reflex is not fully understood. We examined the effect of mandible advancement associated with mouth opening on the coordination between nasal breathing and non-nutritive swallowing induced by continuous infusion of distilled water into the pharyngeal cavity. The combination of mandible advancement and mouth opening increased the duration of swallowing apnoea and submental electromyographic burst duration. When the mandible was advanced with the mouth open, the duration of swallowing apnoea increased significantly compared with the centric position (0.79 +/- 0.23 vs. 0.64 +/- 0.12 s, P < 0.05, n = 12), and the duration of submental electromyographic activity increased significantly (2.11 +/- 0.63 vs. 1.46 +/- 0.25 s, P < 0.05, n = 12). Mandible advancement with mouth opening altered the respiratory phase resetting during swallowing and the timing of swallow in relation to respiratory cycle phase. We conclude that mandible re-positioning may strongly influence the coordination between nasal breathing and non-nutritive swallowing by altering respiratory parameters and by inhibiting movement of the tongue-jaw complex.

PMID: 20337868 [PubMed - indexed for MEDLINE]

Headaches and TMJ Disorders are related to whole body health.

A new article in Practical Pain Management "Head and Neck: Kinetic Chain from the Toes Influences the Craniofacial Region " discusses the kinetic chain and how what happens in the body effects the craniofacial region and how jaw problems, bite stability and joint stability influences the entire body as well. These postural changes are a major cause of Tension-type headaches, neck pain and other types of myalgias.

The field of Posturology is how our posture affects the entire body. Posture includes how we stand, sit, lay down, sleep, work out and more. If we overwork muscles we can cause repetitive strain injuries that lead to myofascial pain and dysfunction.

There are three set points in the body that serve as neuromuscular resetting mechanisms. The teeth when we bite and swallow, our hips when we sit and our feet-legs-hips when we stand.

A second article in the Clinical Journal Pain. 2010 Aug 20. "The Influence of Cranio-cervical Posture on Maximal Mouth Opening and Pressure Pain Threshold in Patients With Myofascial Temporomandibular Pain Disorders." found that their data "supports the biomechanical relationship between the cranio-cervical region and the dynamics of the temporomandibular joint, as well as trigeminal nociceptive processing in different cranio-cervical postures." The trigeminal nociceptive system is integral in almost all chronic headaches and migraines. (abstract below)

Another recent article "Prevalence of temporomandibular disorder-related findings in violinists compared with control subjects" in Oral Surg Oral Med Oral Pathol Oral Radiol looks at the posture of violinists and how it affects TM Joint stability and symptoms. This is a special case of postural distortion. (abstract below)

Head and Neck: Kinetic Chain from the Toes Influences the Craniofacial Region
Practical Pain Management, 08/04/2010
Rubenstein D – This article on plantar toe flexion and the kinetic chain is very interesting and offers an insight that may play a clinical role in diagnosis of TMJ and facial pain of kinetic postural and muscular origin. It serves to demonstrate that the TMJ and cervico/mandibular regions are both influencers of, and are influenced by, postural stresses, degenerative changes and dysfunctions that are often unrecognized by pain management clinicians.

Clin J Pain. 2010 Aug 20. [Epub ahead of print]
The Influence of Cranio-cervical Posture on Maximal Mouth Opening and Pressure Pain Threshold in Patients With Myofascial Temporomandibular Pain Disorders.
La Touche R, París-Alemany A, von Piekartz H, Mannheimer JS, Fernández-Carnero J, Rocabado M.

*School of Health Science, Department of Physical Therapy daggerGroup for Musculoskeletal Pain and Motor Control Clinical Research double daggerOrofacial Pain Unit of the Policlínica Universitaria, Universidad Europea de Madrid, Villaviciosa de Odón paragraph signDepartment of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain section signFaculty of Business, Management and Social Science, University of Applied Science Osnabrück, Osnabrück, Germany parallelProgram in Physical Therapy, Columbia University, New York, NY musical sharpSchool of Rehabilitation Science, Universidad Andres Bello, Santiago, Chile.
Abstract
OBJECTIVE: The aim of this study was to assess the influence of cranio-cervical posture on the maximal mouth opening (MMO) and pressure pain threshold (PPT) in patients with myofascial temporomandibular disorders pain.

MATERIALS AND METHODS: A total of 29 patients (19 females and 10 males) with myofascial temporomandibular disorders pain participated in the study, aged 19 to 59 years (mean years+/-SD; 34.69+/-10.83 y). MMO and the PPT (on the right side) of patients in neutral, retracted, and forward head postures were measured. A 1-way repeated measures analysis of variance followed by 3 pair-wise comparisons were used to determine differences.

RESULTS: Comparisons indicated significant differences in PPT at 3 points within the trigeminal innervated musculature [masseter (M1 and M2) and anterior temporalis (T1)] among the 3 head postures [M1 (F=117.78; P<0.001), M2 (F=129.04; P<0.001), and T1 (F=195.44; P<0.001)]. There were also significant differences in MMO among the 3 head postures (F=208.06; P<0.001). The intrarater reliability on a given day-to-day basis was good with the interclass correlation coefficient ranging from 0.89 to 0.94 and 0.92 to 0.94 for PPT and MMO, respectively, among the different head postures.

CONCLUSIONS: The results of this study shows that the experimental induction of different cranio-cervical postures influences the MMO and PPT values of the temporomandibular joint and muscles of mastication that receive motor and sensory innervation by the trigeminal nerve. Our results provide data that supports the biomechanical relationship between the cranio-cervical region and the dynamics of the temporomandibular joint, as well as trigeminal nociceptive processing in different cranio-cervical postures.

PMID: 20733480 [PubMed - as supplied by publisher]

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2010 Jan;109(1):e15-9.
Prevalence of temporomandibular disorder-related findings in violinists compared with control subjects.
Rodríguez-Lozano FJ, Sáez-Yuguero MR, Bermejo-Fenoll A.

TMD and Orofacial Pain Unit, Faculty of Medicine and Odontology, University of Murcia, Murcia, Spain. fcojavier@um.es
Abstract
OBJECTIVE: The aim of this study was to determine if there is an association between violin playing and the presence of signs and symptoms of temporomandibular disorder (TMD).

STUDY DESIGN: We studied a group of violinists in the Murcia region of Spain, who were examined for TMD. The results were compared with those from a random control group who did not play any musical instrument. The groups were matched by age and gender. Statistical analysis was carried out using SPSS 15.0 statistical software.

RESULTS: Compared with the control subjects, the violinists as a group had significantly more pain in maximum mouth opening (P < .005), parafunctional habits (P = .001), and occurrence of temporomandibular joint sounds (P < .005) as determined by chi-squared.

CONCLUSIONS: Violin playing appears to be a factor associated with TMD-related findings.

PMID: 20123363 [PubMed - indexed for MEDLINE]

Thursday, September 23, 2010

DIZZINESS, HEADACHES, TINNITUS AND FATIGUE CAN BE ADDRESSED WITH NEUROMUSCULAR DENTISTRY.

JAMES: For the last 4 years or so I have suffered from increasing dizziness, headaches, tinnitus and fatigue. I have ground my teeth for years and only recently considered the possibility that TMD could be the cause of my problems. It has gotten to the point that I am nearly unable to work. Could you please give me any information on doctors in the central NY area that would be able to help me. Thank You

DR SHAPIRA: JAMES THE PROBLEMS YOU DISCUSSED CAN FREQUENTLY BE ADDRESSED, ALLEVIATED AND/OR ELIMINATED THRU NEUROMUSCULAR DENTISTRY. THE FIRST STEP WOULD BE A COMPLETE EXAM AND TREATMENT WOULD PROBABLY BEGIN WITH A DIAGNOSTIC ORTHOTIC. I WILL CONTACT YOU WITH THE NAME OF A LOCAL AREA NEUROMUSCULAR DENTIST.

DR SHAPIRA

Glycerol injections of the Trigeminal Nerve for Cluster Headaches

Orville : I have suffered with episodic cluster migraines for years they usually come every other fall. the only thing that has helped me besides oxygen is zomig but I have to take more than the manufacturer recomends. What are the possible complications associated with Glycerol facial injections

Dr Shapira response: Glycerol injections are usually safe and effective but can have advers effects.

I have quoted a reference below that discusses adverse effects such as refractory pain that becomes non-remitting and possibly worse and unresponsive to treatment.

I would recommend utilizing Sphenopalatine Ganglion Blocks (SPG), an autonomic block that can be done transnasaly with no risk almost no risk. Patients can do SPG blocks at home to turn off or prevent attacks. Oxygen is obviously an excellent therap and can be used alone or with SPG blocks. SPG blocks before bed can often prevent an attack if they occur primarily in the night.

Taking more than rx dose of ZOMIG should be discussed with your physician.


Trigeminal Cistern Glycerol Injections for Facial Pain†
Thomas A. Waltz M.D., Donald J. Dalessio M.D., Kenneth H. Ott M.D., Brian Copeland M.D., Gaye Abbott C.M.A.-C.Article first published online: 22 JUN 2005


Headache: The Journal of Head and Face Pain
Volume 25, Issue 7, pages 354–357, October 1985
Dalessio, D. J., Ott, K. H., Copeland, B. and Abbott, G. (1985), Trigeminal Cistern Glycerol Injections for Facial Pain. Headache: The Journal of Head and Face Pain, 25: 354–357.
Publication History Issue published online: 22 JUN 2005
Article first published online: 22 JUN 2005

SYNOPSIS
The treatment of paroxysmal facial pain is often easily accomplished. At times, however, the converse occurs; the pain becomes more refractory, and unresponsive to therapy. This is especially the case when trigeminal neuralgia, cluster headache, and atypical facial pain become chronic. This report will summarize our experience with injection of glycerol into the region of the trigeminal cistern for intractable facial pain in 71 patients; 58 with trigeminal neuralgia, 5 with chronic cluster headache, and 8 with atypical facial pain.

Increased Cortical Activity that causes headaches is increased with sleep apnea.

A recent study in Sleep Med on altered Cortical Excitability in sleep apnea concluded that " This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day."

This may be a major cause of chronic headaches or migraines or other biochemical imbalances leading to stress disorders ofr depression. Many patients do not reach the clinical definition of sleep apnea but have UARS (upper respiratory resistance syndrome). This has been implicated in fibromyalgia and central sensitization as well.

I have included a few relevant pubmed articles below.

Sleep apne is the result of a TMJ disorder (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf)

Neuromuscular Dentistry can help reduce incresed corticl activity, Treatment of sleep apnea can do the same.

Patients with sleep apnea have a smaller airway 24/7 that collapses at night. Correction of apnea and daytime jaw position may be ideal for all patients with chronic pain and sleep apnea.



Sleep Med. 2010 Oct;11(9):857-61.

Altered cortical excitability in patients with untreated obstructive sleep apnea syndrome.
Joo EY, Kim HJ, Lim YH, Koo DL, Hong SB.

Sleep Center, Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.

Comment in:

Sleep Med. 2010 Oct;11(9):820-1.

Abstract
OBJECTIVE: To investigate cortical excitability in patients with obstructive sleep apnea syndrome (OSAS) during wakefulness.

METHODS: The authors recruited 45 untreated severe OSAS (all males, mean age 47.2 years, mean apnea-hypopnea index=44.6h(-1)) patients and 44 age-matched healthy male volunteers (mean apnea-hypopnea index=3.4h(-1)). The TMS parameters measured were resting motor threshold (RMT), motor evoked potential (MEP) amplitude, cortical silent period (CSP), and short-interval intracortical inhibition (SICI) and intracortical facilitation (ICF). These parameters were measured in the morning (9-10 am) more than 2h after arising and the parameters of patients and controls were compared. The Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS) were also measured before the TMS study.

RESULTS: OSAS patients had a significantly higher RMT and a longer CSP duration (t-test, p<0.001) compared to healthy volunteers. No significant difference was observed between MEP amplitudes at any stimulus intensity or between the SICI (2, 3, 5ms) and ICF (10, 15, 20ms) values of OSAS patients and healthy volunteers (p>0.05).

CONCLUSIONS: This TMS-based study suggests that untreated severe OSAS patients have imbalanced cortical excitabilities that enhanced inhibition or decreased brain excitability when awake during the day.

PMID: 20817550 [PubMed - in process]

Handb Clin Neurol. 2010;97:73-83.

Biological science of headache channels.
Pietrobon D.

Abstract
Several episodic neurological diseases, including familial hemiplegic migraine (FHM) and different types of epilepsy, are caused by mutations in ion channels, and hence classified as channelopathies. The classification of FHM as a channelopathy has introduced a new perspective in headache research and has strengthened the idea of migraine as a disorder of neural excitability. Here we review recent studies of the functional consequences of mutations in the CACNA1A and SCNA1A genes (encoding the pore-forming subunit of Ca(V)2.1 and Na(V)1.1 channels) and the ATPA1A2 gene (encoding the alpha(2) subunit of the Na(+)/K(+) pump), responsible for FHM1, FHM3, and FHM2, respectively. These studies show that: (1) FHM1 mutations produce gain-of-function of the Ca(V)2.1 channel and, as a consequence, increased glutamate release at cortical synapses and facilitation of induction and propagation of cortical spreading depression (CSD); (2) FHM2 mutations produce loss-of-function of the alpha(2) Na(+)/K(+)-ATPase; and (3) the FHM3 mutation accelerates recovery from fast inactivation of Na(V)1.5 channels. These findings are consistent with the hypothesis that FHM mutations share the ability to render the brain more susceptible to CSD, by causing excessive synaptic glutamate release (FHM1) or decreased removal of K(+) and glutamate from the synaptic cleft (FHM2) or excessive extracellular K(+) (FHM3).

PMID: 20816411 [PubMed - in pr

Handb Clin Neurol. 2010;97:47-71.

Pharmacology.
Bolay H, Durham P.

Department of Neurology, Gazi Hospital and Neuropsychiatry Centre, Gazi University, Besevler, Ankara, Turkey.

Abstract
Headache treatment has been based primarily on experiences with non-specific drugs such as analgesics, non-steroidal anti-inflammatory drugs, or drugs that were originally developed to treat other diseases, such as beta-blockers and anticonvulsant medications. A better understanding of the basic pathophysiological mechanisms of migraine and other types of headache has led to the development over the past two decades of more target-specific drugs. Since activation of the trigeminovascular system and neurogenic inflammation are thought to play important roles in migraine pathophysiology, experimental studies modeling those events successfully predicted targets for selective development of pharmacological agents to treat migraine. Basically, there are two fundamental strategies for the treatment of migraine, abortive or preventive, based to a large degree on the frequency of attacks. The triptans, which exhibit potency towards selective serotonin (5-hydroxytryptamine, 5-HT) receptors expressed on trigeminal nerves, remain the most effective drugs for the abortive treatment of migraine. However, numerous preventive medications are currently available that modulate the excitability of the nervous system, particularly the cerebral cortex. In this chapter, the pharmacology of commercially available medications as well as drugs in development that prevent or abort headache attacks will be discussed.

PMID: 20816410 [PubMed - in process]

Cephalalgia. 2010 Sep;30(9):1101-9. Epub 2010 Mar 19.

Cortical hyperexcitability and mechanism of medication-overuse headache.
Supornsilpchai W, le Grand SM, Srikiatkhachorn A.

Department of Physiology, Faculty of Medicine, Chulalongkorn University, Patumwan, Bangkok, Thailand.

Abstract
The present study was conducted to determine the effect of acute (1 h) and chronic (daily dose for 30 days) paracetamol administration on the development of cortical spreading depression (CSD), CSD-evoked cortical hyperaemia and CSD-induced Fos expression in cerebral cortex and trigeminal nucleus caudalis (TNC). Paracetamol (200 mg/kg body weight, intraperitonealy) was administered to Wistar rats. CSD was elicited by topical application of solid KCl. Electrocorticogram and cortical blood flow were recorded. Results revealed that acute paracetamol administration substantially decreased the number of Fos-immunoreactive cells in the parietal cortex and TNC without causing change in CSD frequency. On the other hand, chronic paracetamol administration led to an increase in CSD frequency as well as CSD-evoked Fos expression in parietal cortex and TNC, indicating an increase in cortical excitability and facilitation of trigeminal nociception. Alteration of cortical excitability which leads to an increased susceptibility of CSD development can be a possible mechanism underlying medication-overuse headache.

PMID: 20713560 [PubMed - in process]

My Headaches are throbbing, nausea, stabbing ....Renee

Heeadaches related to the trigeminal nerves and jaw function frequently have all of those qualities. This relates to the vascular, hemodynamic and autonomic functions of the trigeminal nerve. Neuromuscular dentistry can frequently allieve and eliminate these sypmtoms as well as the more common tender, aching, and penetrating headaches. Painful TM Joint symptoms may or may not be present.

HEADACHES,TMJ AND ORTHOMOLECULAR MEDICINE

Question rrom Phil Bohnert, MD How about ortho-molecular treatments?

Reply: Orthomolecular Medicine is a term originally coined by Linus Pauling one of the greatest minds of the last century. It is medicine that idealizes the health of the total individual by correcting or optimizing the nutritional and biochemical stautus of the body.

Neuromuscular Dentistry is a form of orthomolecular medicine optimizing and correcting not nutritional but neurological input into the trigeminal nerve. The trigeminal nerve accounts for almost half of total input to the brain.

There are corrections in biochemical homeostasis at neurojunctions when it is optimized. There are also major changes to brain chemistry from control of blood flow to the brain br the trigeminal nerve.

Thank You Dr Bonnert

Sunday, August 22, 2010

TMJ Treatment: Is Neuromuscular Dentistry the TMJ Treatment?

Neuromuscular Dentistry treats TMJ disorders by correcting the underlying problems rather than just treating the symptoms. The old fashioned mechanical approach to TMD treatment only addresses the current symptoms. Long term correction of chronic headaches, joint pain and muscle pain is actually the result of healing when underlying pathology is eliminated. Neuromuscular Dentistry is the best way to correct function and permit long term healing.

Monday, August 16, 2010

Headaches after wisdom teeth extractions and residual paresthesia.

Question from ELMA:
What is the correlation between the removal of the third molar and migraine headaches? I have permanent paresthesia on the lower left lip and chin. This occured in 1987 and I never suffered with headaches or sinus problems until the surgery. I remember hearing the dentist asking his assistant "What is that?" once he extracted that particular tooth.

Dr Shapira Response: Dear Elma I have seen many patients who trace TMJ problems and headaches back to wisdom teeth extractions. This can be due to many reasons. You had damage to your trigeminal nerve during the surgery that causes parasthesia or permanent numbness.

It is also traumatic to the joints, ligaments and muscles to have third molars extracted. Injuries may not always heal correctly and bites can change leading to neuromuscular problems.

Frequently there were always underlying problems that do not express themselves until after extractions. Clicking can start in the TM Joints due to direct trauma to the joint or secondary to bite changes.

I am hoping my patented devices for early prophylactic removal or third molars before they calcify will eliminate most of this type of problem in the future. There is virtually no morbidity when the developing tooth bud is removed before calcification and it is a quick atraumatic procedure with the added benefit of allowing collection and storage of stem cells for future use.

Relief of 30 years of constant Headache: Brief relief may provide clue to long term relief.

KEN:I Have had headaches for 30 years going away only once when having a root canal done on an upper tooth. While everything was numbed up I had complete brain function and no headache. They are located directly behind my nose area and I feel a constant pressure.

Dr Shapira response: The anaesthetic relieved the pain probably confirming that it is from the trigeminal nerve. I would be very interested is a spenopalatine ganglion block could give more long term relief. It is a easy procedure that I have taught patients to do at home with a q-tip and anaesthetic thru the nose. There are also other diagnostic blocks that can be done to determine the cause of your headaches.

A diagnostic neuromuscular orthotic would be an excellent first step in treatment. If the headaches are eliminated or significantly relieved a permenant stabilization could be done. I have referred you to an excellent Dr who knows both of the procedures mentioned.

Friday, July 30, 2010

Migraine is Most Common Primary Headache in Patients with Temporomandibular Disorders

A recent article in the Journal of Orofacial Pain identifies Migraine as the most frequent primary headache in patients with temporomandibular disorders. The majority of migraines are actually trigeminally moderated and it is no surprise that they would be common. Tension type headaches were the second most common headache. Headaches occured in 45.6 % of control group and 85.5 % of TMD group.

Patients with chronic migraines and tension headaches who are looking for relief should consider the utilization of neuromuscular dentistry.

A neuromuscular diagnostic orthotic is the first step in changing the quality of life. It is a well established fact that the trigeminal nerves are an integral part of most chronic migraine and tension headaches. Neuromuscular dentistry is probably the best approach to correcting the physiologic causes of migraine. Aitional information on the treatment of TMJ disorders and chronic headaches utilizing neuromuscular dentistry cn be found in Sleep and Health Journal.



J Orofac Pain. 2010 Summer;24(3):287-92.
Migraine is the Most Prevalent Primary Headache in Individuals with Temporomandibular Disorders.
Franco AL, Goncalves DA, Castanharo SM, Speciali JG, Bigal ME, Camparis CM.

Abstract
Aims: To assess the prevalence of primary headaches (HA) in adults with temporomandibular disorders (TMD) who were assessed in a specialty orofacial pain clinic, as well as in controls without TMD. Methods: The sample consisted of 158 individuals with TMD seen at a university-based specialty clinic, as well as 68 controls. The Research Diagnostic Criteria for TMD were used to diagnose the TMD patients. HAs were assessed using a structured interview and classified according to the Second Edition of the International Classification for Headache Disorders. Data were analyzed by chi-square tests with a significance level of 5% and odds ratio (OR) tests with a 95% confidence interval (CI). Results: HAs occurred in 45.6% of the control group (30.9% had migraine and 14.7% had tension-type headache [TTH]) and in 85.5% of individuals with TMD. Among individuals with TMD, migraine was the most prevalent primary HA (55.3%), followed by TTH (30.2%); 14.5% had no HA. In contrast to controls, the odds ratio (OR) for HA in those with TMD was 7.05 (95% confidence interval [CI] = 3.65-13.61; P = .000), for migraine, the OR was 2.76 (95% CI = 1.50-5.06; P = .001), and for TTH, the OR was 2.51 (95% CI = 1.18-5.35; P = .014). Myofascial pain/arthralgia was the most common TMD diagnosis (53.2%). The presence of HA or specific HAs was not associated with the time since the onset of TMD (P = .714). However, migraine frequency was positively associated with TMD pain severity (P = .000). Conclusion: TMD was associated with increased primary HA prevalence rates. Migraine was the most common primary HA diagnosis in individuals with TMD. J Orofac Pain 2010;24:287-292.

PMID: 20664830 [PubMed - in process]

Tuesday, July 20, 2010

NERVE BLOCKS AND TRIGGER POINT INJECTIONS IN THE TREATMENT OF CHRONIC HEADACHES

A new study "Patterns of use of peripheral nerve blocks and trigger point injections among headache practitioners in the USA: Results of the American Headache Society Interventional Procedure Survey (AHS-IPS)" in Headache found widespread use of trigger point injections and nerve blocks it headache treatment. Many Neuromuscular dentists have a great deal of expertise in the utilization of these injections as part of coordinated treatment for Migraines, Tension-Type headaches and TMJ disorders.

Neuromuscular Dentists recognize that these injections are effective but do not address the underlying causes of patients problems. Correction of the Neuromuscular relationships and trigeminal nerve innervated muscles function is the key to long term correction of these problems. When diagnostic blocks and trigger points are effective the next step is to utilize a diagnostic orthotic to reduce noxious input to the Trigeminal nervous system and correct underlying postural pathology.

Headache. 2010 Jun;50(6):937-42.
Patterns of use of peripheral nerve blocks and trigger point injections among headache practitioners in the USA: Results of the American Headache Society Interventional Procedure Survey (AHS-IPS).
Blumenfeld A, Ashkenazi A, Grosberg B, Napchan U, Narouze S, Nett B, DePalma T, Rosenthal B, Tepper S, Lipton RB.

The Headache Center of Southern California, Encinitas, CA, USA.
Comment in:

Headache. 2010 Jun;50(6):953-4.
Abstract
BACKGROUND: Many clinicians use peripheral nerve blocks (NBs) and trigger point injections (TPIs) for the treatment of headaches. Little is known, however, about the patterns of use of these procedures among practitioners in the USA. OBJECTIVES: The aim of this study was to obtain information on patterns of office-based use of peripheral NBs and TPIs by headache practitioners in the USA. METHODS: Using an Internet-based questionnaire, the Interventional Procedures Special Interest Section of the American Headache Society (AHS) conducted a survey among practitioners who were members of AHS on patterns of use of NBs and TPIs for headache treatment. RESULTS: Electronic invitations were sent to 1230 AHS members and 161 provided usable data (13.1%). Of the responders, 69% performed NBs and 75% performed TPIs. The most common indications for the use of NBs were occipital neuralgia and chronic migraine (CM), and the most common indications for the use of TPIs were chronic tension-type headache and CM. The most common symptom prompting the clinician to perform these procedures was local tenderness at the intended injection site. The most common local anesthetics used for these procedures were lidocaine and bupivacaine. Dosing regimens, volumes of injection, and injection schedules varied greatly. There was also a wide variation in the use of corticosteroids when performing the injections. Both NBs and TPIs were generally well tolerated. CONCLUSIONS: Nerve blocks and TPIs are commonly used by headache practitioners in the USA for the treatment of various headache disorders, although the patterns of their use vary greatly.

PMID: 20618812 [PubMed - in process]

Saturday, July 17, 2010

ARURICULAR NERVE STIMULATION FOR TREATING MIGRAINE vs NEUROMUSCULAR DENTISTRY AND DIAGNOSTIC ORTHOTIC TREATMENT

An article in Headache "Implanted auriculotemporal nerve stimulator for the treatment of refractory chronic migraine' (see abstract below) reports on a case of refractory headache with phonopobia treated by implanted peripheral nerve stimulators. Treatment reduced but did not eliminate the patients pain. The authors chose to only treat only a single branch of the mandibular nerve and did not address the entire Trigeminal Nervous system. A second article in Headache "Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome." discusses the use of occipital nerve blocks in treating migraines. The correction of forward head position thru neuromuscular dentistry can frequently eliminate the need for these blocks.

The ULF-TENS utilized by Neuromuscular Dentistry stimulates all three divisions of the Trigeminal nerve. The anti-dromic stimulation also causes plsing and relaxation of the masticatory muscles. A diagnostic orthotic is used to continually reduce the noxious input to the Trigeminal system which is implicated in almost all migraines and most headaches. The trigeminal nerve is often referred to as the dentist's nerve. Neuromuscular dentists often utilize occipital nerve blocks during treatment but can also utilize ULF TENS of he XI cranial nerve, the accessory nerve to eliminate or reduce the need for these blocks.

According to Wikipedia ""The auriculotemporal nerve is a branch of the mandibular nerve that runs with the superficial temporal artery and vein, and provides sensory innervation to various regions on the side of the head" The orgin of the nerve "arises as two roots from the posterior division of the mandibular nerve (The mandibular nerve is a branch of the trigeminal nerve). These roots encircle the middle meningeal artery (a branch of the mandibular part of the maxillary artery, which is in turn a terminal branch of the external carotid artery). The roots then converge to form a single nerve."
The clinical significance according to Wikipedia is "This nerve as it courses posteriorly to the condylar head, is frequently injured in temporomandibular joint surgery, causing an ipsilateral parasthesia of the auricle and skin surrounding the ear. Actually, it is the main nerve that supplies the TMJ, along with branches of the masseteric nerve and the deep temporal."

This does seem to explain one more reason why Neuromuscular Dentistry is so successful at long term prevention, elimination and treatment of of migraines and other headaches. TMJ disorders are frequently called "The Great Imposter" .

An article in Sleep and Health Journal "SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTOR" can be found at http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor as well as another article originally published by the American Equilibration Society that discusses the scientific basis for Neuromuscular Dentistry http://www.sleepandhealth.com/neuromuscular-dentistry

The treatment of migraines with peripheral nerve stimulators is an excellent idea but only after a trial of a Neuromuscular Orthotic has not proven successful. Neuromuscular Dentistry leads to healing of the entire trigeminal nervous system as well as correcting cervical and orthopedic problems that interfere with complete relief.

An excellent dermatone distribution of the Trigeminal and occipital nerves can be found at http://en.wikipedia.org/wiki/File:Gray784.png

te connections of the trigeminal nerves and occipital nerves are furher explored in "Functional connectivity between trigeminal and occipital nerves revealed by occipital nerve blockade and nociceptive blink reflexes" (see link below)
http://www.clusterattack.com/blog/wp-content/uploads/2009/11/busch-2006-functional-connectivity-between-trigeminal-and-occipital-nerves-revealed-by-occipital-nerve-blockade-and-nociceptive-blink-reflexes.pdf

The summary of this article notes the occipital nerve and trigeminal nerve connections. These explain why occipital migraines and cervical pain are relieved thru neuromuscular dental treatment when it is not explained by cervical orthopedic corrections.

Headache. 2010 Jun;50(6):1064-9.
Implanted auriculotemporal nerve stimulator for the treatment of refractory chronic migraine.
Simopoulos T, Bajwa Z, Lantz G, Lee S, Burstein R.

Beth Israel Deaconess Medical Center - Anesthesia, Boston, MA, USA.
Abstract
OBJECTIVE: To report a case of improved pain control and function in a patient with chronic migraine after treatment with auriculotemporal nerve stimulation. METHODS: The patient is a 52-year-old woman with refractory pain in the bilateral temporal distribution and marked phonophobia as a result of chronic migraine. RESULTS: After a successful trial period, the patient underwent implantation of bilateral peripheral nerve stimulators targeting the auriculotemporal nerves. At 16 months of follow up, her average pain intensity declined from 8-9/10 on the numeric rating scale to 5/10. Her function improved as assessed by the Migraine Disability Assessment, from total disability (grade IV) to mild disability (grade II). Her phonophobia became far less debilitating. CONCLUSION: Auriculotemporal nerve stimulation may be useful tool in the treatment of refractory pain in the temporal distribution due to chronic migraine.

FROM WIKIPEDIA AURICULARTEMPORAL NERVE

"The auriculotemporal nerve is a branch of the mandibular nerve that runs with the superficial temporal artery and vein, and provides sensory innervation to various regions on the side of the head"

"Origin
The auriculotemporal nerve arises as two roots from the posterior division of the mandibular nerve (The mandibular nerve is a branch of the trigeminal nerve). These roots encircle the middle meningeal artery (a branch of the mandibular part of the maxillary artery, which is in turn a terminal branch of the external carotid artery). The roots then converge to form a single nerve.

Course
The auriculotemporal nerve passes laterally to the neck of the mandible, gives off parotid branches and then turns superiorly, posterior to its head and moving anteriorly, gives off anterior branches to the auricle. It then crosses over the root of the zygomatic process of the temporal bone, deep to the superficial temporal artery

Innervation
The somatosensory root (superior) originates from branches of the mandibular nerve, which pass through the otic ganglion without synapsing. Then they form the somatosensory (superior) root of the auriculotemporal nerve. The two roots re-unite and shortly after the branching of secretomotor fibers to the parotid gland (parotid branches) the auriculotemporal nerve comprises exclusively somatosensory fibers, which ascend to the superficial temporal region. Supplies the auricle, external acoustic meatus, outer side of the tympanic membrane and the skin in the temporal region (superficial temporal branches). It also carries a few articular branches which go on to supply the temporomandibular joint.
The parasympathetic root (inferior) carries postganglionic fibers to the parotid gland. These parasympathetic, preganglionic secretomotor fibers originate from the glossopharyngeal nerve (CN IX) as one of its branches, the lesser petrosal nerve. This nerve synapses in the otic ganglion and its postganglionic fibers form the inferior, parasympathetic root of the auriculotemporal nerve. The two roots re-unite and shortly after the "united" auriculotemporal branch gives off parotid branches, which serve as secretomotor fibers for the parotid gland.

Clinical significance

This nerve as it courses posteriorly to the condylar head, is frequently injured in temporomandibular joint surgery, causing an ipsilateral parasthesia of the auricle and skin surrounding the ear. Actually, it is the main nerve that supplies the TMJ, along with branches of the masseteric nerve and the deep temporal.
After a parotidectomy, the nerves from the Auriculotemporal Nerve that previously innervated the parotid gland can reattach to the sweat glands in the same region. The result is sweating along the cheek with the consumption of foods (Frey's syndrome). Treatment involves the application of an antiperspirant or glycopyrrolate to the cheek, Jacobsen's neurectomy along the middle ear promontory, and lifting of the skin flap with the placement of a tissue barrier (harvested or cadaveric) to interrupt the misguided innervation of the sweat glands.
Pain related to a condition call parotiditis, or commonly referred to as " the mumps" will be carried by the auriculotemporal nerve."

Headache. 2010 Jun;50(6):1041-4.
Suboccipital nerve blocks for suppression of chronic migraine: safety, efficacy, and predictors of outcome.
Weibelt S, Andress-Rothrock D, King W, Rothrock J.

University of Alabama Headache, Treatment and Research Program, University of Alabama School of Medicine, Birmingham, AL, USA.
Abstract
BACKGROUND: Approximately 1 in 50 Americans is afflicted by chronic migraine (CM). Many patients with CM describe cervicogenic headache. Options for treating CM effectively are at present quite limited. OBJECTIVE: To determine the safety and efficacy of occipital nerve blocks (ONBs) used to treat cervicogenic chronic migraine (CCM) and to identify variables predictive of a positive treatment response. METHODS: Using a uniform dose and injection paradigm, we performed ONBs consecutively on a series of patients presenting with CCM. Patients were stratified according to specific findings found to be present or absent on physical examination. A positive treatment outcome was defined as a 50% or greater reduction in headache days per month over the 30 days following treatment relative to the 30-day pre-treatment baseline. We used a 5-point Likert scale as one of the secondary outcome variables. RESULTS: We treated 150 consecutive patients with unilateral (37) or bilateral (113) ONBs. At the 1-month follow-up visit 78 (52%) exhibited evidence of a positive treatment response according to the primary outcome variable, and 90 (60%) reported their headache disorder to be "better" (44; 29%) or "much better" (46; 30%). A total of 8 (5%) patients reported adverse events within the ensuing 72 hours, and 3 (2%) experienced adverse events that reversed spontaneously but required emergent evaluation and management. CONCLUSION: For suppression of CCM, ONBs may offer an attractive alternative to orally administered prophylactic therapy.

PMID: 20618817 [PubMed - in process]