Chronic pain is frequently multifactorial in nature. Neuromuscular dentistry has been very successful in treating TMD, Migrines, Tension Type headaches and other disorders. Frequently it is not a total cure but 50-80% reduction in pain is usually attained within several visits. There are many disorders and symptoms associated with TMD including:
Ear Aches or Otalgia
Sinus Pain
TM Joint Clicking and Popping
Ear Stuffiness or Eustacian Tube Dysfunction
Dizziness
Vertigo
Temporal Pain
Occipital Headaches
Morning Headaches
Sleep Apnea
Snoring
Sore Throats
Neck pain or stiffness
Feelings of a foriegn object in the throat
Pain in or behind the eyes
Scalp pain or feeling like your hair hurts
Most of these symptoms are mediated by the Trigeminal nerve and the Trigeminovaqscular system. These Nerves also connect to facial nerves, occipital nerves, glossopharyngeal nerves and to the autonomic nervous system. What happens in these nerves cause biochemical changes in the brain. Recent stuies shown the neural plasticity can create permanent changes in the brain. If chronic pain is the stimulus it can lead to central sensitization.
Changes inthe brain can be reversed over time but the exact amount of recovery will vary with individual patients genotypes, how long the pain has been present , other comorbidities that the patient carries. Some patients experience immediate3 and almost miraculous pain relief while others have a slower longer version of recovery. I always tell my patients to work for 50 - 80% improvement in pain. That is then our new starting point and we again seek 50 - *0 % reduction in pain.
There is "no cure" for long term chronic pain because lives have been changed due to living with pain. A cure would require a do-over of the years you had pain. There are no do-overs therefore we look to improve your future quality of life to the maximum. Some patients still have to do exercises or watch diet or even continue different medications. Other patients have remarkably and incredible improvements as described by Dr Barry Cooper in Cranio where he talked about "overwhelming success". This is why we use a diagnostic orthotic as the first step of treatment. We try to avoid permanent changes until the patient feels substantially improved. This is not a judgement that any doctor can make for the patient. It is a subjective evaluation by the patient themselves. Only the patient knows how well or poorly they are doing. We may have objective data showing physical improvement but the final test is have we improved or dramatically improved the patients quality of life. If the answer is yes we can talk about long term stabilization. The diagnostic orthotic is the first phase of treatment for those patients.
If the patient has improvement, whether it is only 25-30% or if they are at 80-90% the decision that the diagnostic orthotic treatment is successful remains the patient's. If they do not feel sufficiently improved they should not feel pressured into continuing treatment or making permanent changes. You should treat the diagnostic orthotic like a CAT SCAN or MRI but instead of images we have improvement in the quality of life. If improvement is not sufficient then a diagnostic approach should continue.
While NEUROMUSCULAR DENTISTRY IS REMARKABLY EFFECTIVE AT TREATING MANY CONDITIONS THERE ARE OTHER CONDITIONS THAT ARE NOT RELATED TO THE TRIGEMINAL NERVOUS SYSTEM, MYOFASCIAL PAIN OR JAW JOINTS.
TMJ disorders are frequently called The Great Imposter ("SUFFER NO MORE: DEALING WITH THE GREAT IMPOSTER" IS A MUST READ FOR ANY PATIENTS WITH MIGRAINES OR TMD http://www.sleepandhealth.com/story/suffer-no-more-dealing-great-impostor) but we must remember that other disorders can also masquerade or more frequently coexist with these problems. Many times a diagnostic orthotic relieves many of the symptoms but the remaining symptoms have a different cause. The expression that "you can't see the forest for the trees" applies. When the majority of symptoms are relieved you now find that you can identify a particular problem that was lost in a long and winding maze of symptoms. As NMD unravels the maze a specific problem can now be identified and treated.
Sunday, February 28, 2010
Friday, February 26, 2010
MYOFASCIAL TRIGGER POINTS ARE EXPLAINED: TMJ disorders discussed at 2010 American Equilibration Society Meeting: New Hope for Headache Sufferers
I just attended the 2010 American EquilibrationSociety meetng in Chicago titled "TREATING THE TMD PATIENT: Putting the Puzzle pieces together". Great news for patients with migraines, tension headaches and Temporomandibular disorders.
The meeting opened with an excellent letter by Henry Gremillion, who was recently named Dean of the Louisiana School of Dentistry. He spoke on "MYOGENOUS OROFACIAL PAIN" or pain coming from the muscles. It is well known that the majority of pain has orgins in the muscles, including tension-type headaches and chronic daily headaches as well as most pain associated with TMD disorders.
Dr Gremillion quoted a scary study where a single injection of nerver growth factor, a compound found in sore muscles and around trigger points could activate nociception (pain) for up to 7 weeks not just in the area of injection but in distant muscular and joint areas. Because nerve growth factor is also released in painful areas it explains why treatment can take weeks to show effectiveness. These biochemical changes are associated with neuralplasticity and central sensitization.
There is also a cmlative effect where up to 50 first order neurons can feed into a single second order neuron leading to referred pain and explaining some of the complexity of dealing with headaches coming from muscles but mediated thru the trigeminal nerve and trigeminovascular system resulting in biochemical changes in the brain. While many physicians and some dentists seek to treat this pain with enormous amounts of medications it is possible to change the neural input and and positively effect the CNS (central nervous system) Chemical inbalnces in the brain can be triggered by peripheral nervous system input. A point that was emphasized by the second speaker Dr Jay Shah of the NIHwhose lecture "NEW FRONTIERS IN THE PATHOSPHYSIOLGY OF MUSCULOSKELETAL PAIN : ENTER THE MATRIX" was truly extraordinary in explaining the biochemical changes that occurs in and around trigger points.
Even more exciting is the use of ultrasound imaging and especially vibrational sonoelastography to measure the stiffness around myofascial trigger points and to show the effects on blood flow in the immediate vicinity of trigger points. He also showed that the same biological and chemical changes occur around both latent and active trigger points. These peripheral changes create central nrvous sytem biochemical changes via afferent nerves. He discussed how pain can be due to noxious stimulus or loss of "DESCENDING INHIBITION OF PAIN" AND HOW INHIBITORY NERVE APOPTOSIS CAN CREATE PERMANENT PAIN STATES. TIME IS OF THE ESSENCE IN ADDRESSING NEUROMUSCULAR PAIN! Dr Shaw is a senior staff physiatrist in the rehabilitation medicine dept. After hearing him speak about the treatment of pain and basic research into underlying causes I believe at least some of our tax dollars are truly being used wisely.
His croup does micrassay of the chemicals around myofascial trigger points and they are now using miniscule accupunture needles which have two chanels prepared with lasers to collect chemical assays painlessly with minimal disruption to the tissues. The work he describes should make all patients with myofascial pain and /or fibromyalgia hopeful for better lives with pain controlled. These studies put the rest the idea that TMJ disorders are psychosocial or physical. There is no longer any doubt about the medical nature of these muscle disorders.
Patients with chronic headaches and migraines will surely benefit as this type of research flourishes. This research is also proving the validity of many basic precepts of neuromuscular dentistry. Correction of periheral problems that sey off muscle nociceptors and endogenous biochemicals cause amplification and perpetuation of peripheral and central sensitization that lead to persistent pain.
DR GREMILLION ALSO DISCUSSED VARIOUS ETIOLOGICAL HYPOTHESIS OF CHRONIC MUSCLE PAIN THAT ALL CORRELATED WITH NEUROMUSCULAR DENTISTRY TREATMENT. The central hypothesis dealth with first order to second order neuron ratios, the repetitve strain hypothesis is exactly what neuromuscular dentistry treats with microtrauma leading to macro problems. The peripheral sensitization hypothesis explains how microtrauma can cause central sensitization and the central biasing Mechanism hypothesis explains the equilibrium shifts as facilitation and inhibition ratios shift. He also discussed Sympathetic Dysregulation that can lead to Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndromes (CRPS)
The meeting opened with an excellent letter by Henry Gremillion, who was recently named Dean of the Louisiana School of Dentistry. He spoke on "MYOGENOUS OROFACIAL PAIN" or pain coming from the muscles. It is well known that the majority of pain has orgins in the muscles, including tension-type headaches and chronic daily headaches as well as most pain associated with TMD disorders.
Dr Gremillion quoted a scary study where a single injection of nerver growth factor, a compound found in sore muscles and around trigger points could activate nociception (pain) for up to 7 weeks not just in the area of injection but in distant muscular and joint areas. Because nerve growth factor is also released in painful areas it explains why treatment can take weeks to show effectiveness. These biochemical changes are associated with neuralplasticity and central sensitization.
There is also a cmlative effect where up to 50 first order neurons can feed into a single second order neuron leading to referred pain and explaining some of the complexity of dealing with headaches coming from muscles but mediated thru the trigeminal nerve and trigeminovascular system resulting in biochemical changes in the brain. While many physicians and some dentists seek to treat this pain with enormous amounts of medications it is possible to change the neural input and and positively effect the CNS (central nervous system) Chemical inbalnces in the brain can be triggered by peripheral nervous system input. A point that was emphasized by the second speaker Dr Jay Shah of the NIHwhose lecture "NEW FRONTIERS IN THE PATHOSPHYSIOLGY OF MUSCULOSKELETAL PAIN : ENTER THE MATRIX" was truly extraordinary in explaining the biochemical changes that occurs in and around trigger points.
Even more exciting is the use of ultrasound imaging and especially vibrational sonoelastography to measure the stiffness around myofascial trigger points and to show the effects on blood flow in the immediate vicinity of trigger points. He also showed that the same biological and chemical changes occur around both latent and active trigger points. These peripheral changes create central nrvous sytem biochemical changes via afferent nerves. He discussed how pain can be due to noxious stimulus or loss of "DESCENDING INHIBITION OF PAIN" AND HOW INHIBITORY NERVE APOPTOSIS CAN CREATE PERMANENT PAIN STATES. TIME IS OF THE ESSENCE IN ADDRESSING NEUROMUSCULAR PAIN! Dr Shaw is a senior staff physiatrist in the rehabilitation medicine dept. After hearing him speak about the treatment of pain and basic research into underlying causes I believe at least some of our tax dollars are truly being used wisely.
His croup does micrassay of the chemicals around myofascial trigger points and they are now using miniscule accupunture needles which have two chanels prepared with lasers to collect chemical assays painlessly with minimal disruption to the tissues. The work he describes should make all patients with myofascial pain and /or fibromyalgia hopeful for better lives with pain controlled. These studies put the rest the idea that TMJ disorders are psychosocial or physical. There is no longer any doubt about the medical nature of these muscle disorders.
Patients with chronic headaches and migraines will surely benefit as this type of research flourishes. This research is also proving the validity of many basic precepts of neuromuscular dentistry. Correction of periheral problems that sey off muscle nociceptors and endogenous biochemicals cause amplification and perpetuation of peripheral and central sensitization that lead to persistent pain.
DR GREMILLION ALSO DISCUSSED VARIOUS ETIOLOGICAL HYPOTHESIS OF CHRONIC MUSCLE PAIN THAT ALL CORRELATED WITH NEUROMUSCULAR DENTISTRY TREATMENT. The central hypothesis dealth with first order to second order neuron ratios, the repetitve strain hypothesis is exactly what neuromuscular dentistry treats with microtrauma leading to macro problems. The peripheral sensitization hypothesis explains how microtrauma can cause central sensitization and the central biasing Mechanism hypothesis explains the equilibrium shifts as facilitation and inhibition ratios shift. He also discussed Sympathetic Dysregulation that can lead to Reflex Sympathetic Dystrophy (RSD) or Complex Regional Pain Syndromes (CRPS)
Tuesday, February 23, 2010
Thyroid problems,sleep disordrs, headache and Neuromuscular Dentistry
Patients with thyroid problems frequently also have headaches, TMJ disorders and sleep disorders. The treatment of pain disorders frequently is aided by normalization of thyroid hormone. Free T3 is the activ e form of thyroid hormone and appears to be the most important thyroid hormone when dealing with chronic pain problems.
In the midwest theree is low naturally occuring iodine in the water. Patients with low thyroid and high TSH can frequently be helped by nutritional supplements containing iodine. 1 of drop of iodine in 8 oz of water every other day may be enough iodine to allow the thyroid to function normally. Many years age the Panda bears in Washington DC were unable to conceive. My uncle Dr Al Lepkovsky determined it was because of low thyroid. He added iodine to the water their bamboo shoots were grown in and their thyroid normalized and the pandas conceived and gave birth. Unfortunately they rolled on to of baby pandas and suffocated them.
Low thyroid is frequently treated with synthroid. Synthroid is the inactive (T4) form of thyroid hormone and many people are unable to convert it to T# the active form of the hormone. High TSH will be reduced by taking synthroid even if the active T3 is not increased at all. It has recently become more difficult to get natural Armour thyroid and many patients are getting it from Canada or compounding pharmacies. This is due to a questionable ruling by the FDA questioning the safety of Armour Thyroid natural thyroid hormone in spite of a 100 year safety history.
Sleep disruption can also cause aberrations in thyroid hormone levels. Sleep apnea is one type of sleep disruption. See http://www.ihatecpap.com for more information on the dangers of sleep apnea and treatment alternatives.
The frequent headaches, migraines and chronic daily headaches can be helped by a neuromuscular dental orthotic and/or by stabilizing thyroid hormone, particularly Free T3.
Patients with chronic headaches and migraines should have a thyroid evaluation done as well as sleep testing and neuromuscular dental evaluation.
In the midwest theree is low naturally occuring iodine in the water. Patients with low thyroid and high TSH can frequently be helped by nutritional supplements containing iodine. 1 of drop of iodine in 8 oz of water every other day may be enough iodine to allow the thyroid to function normally. Many years age the Panda bears in Washington DC were unable to conceive. My uncle Dr Al Lepkovsky determined it was because of low thyroid. He added iodine to the water their bamboo shoots were grown in and their thyroid normalized and the pandas conceived and gave birth. Unfortunately they rolled on to of baby pandas and suffocated them.
Low thyroid is frequently treated with synthroid. Synthroid is the inactive (T4) form of thyroid hormone and many people are unable to convert it to T# the active form of the hormone. High TSH will be reduced by taking synthroid even if the active T3 is not increased at all. It has recently become more difficult to get natural Armour thyroid and many patients are getting it from Canada or compounding pharmacies. This is due to a questionable ruling by the FDA questioning the safety of Armour Thyroid natural thyroid hormone in spite of a 100 year safety history.
Sleep disruption can also cause aberrations in thyroid hormone levels. Sleep apnea is one type of sleep disruption. See http://www.ihatecpap.com for more information on the dangers of sleep apnea and treatment alternatives.
The frequent headaches, migraines and chronic daily headaches can be helped by a neuromuscular dental orthotic and/or by stabilizing thyroid hormone, particularly Free T3.
Patients with chronic headaches and migraines should have a thyroid evaluation done as well as sleep testing and neuromuscular dental evaluation.
Neuromuscular Dentistry, Central Sensitization and Trigeminal Neuralgia: Is Neuromuscular Dentistry an ideal method to prevent central sensitization?
A new article in Medical Hypothesis (see Pub Med abstract below) on Atypical Trigeminal Neuralgia discusses the pathogenisis of Central Sensitization in patients with Trigeminal Neuralgia. A percentage of patients with Trigeminal Neuralgia will have pressure on the trigeminal nerve either from blood vessels or tumors usually in the area of the foramen ovale.
Many patients who have trigeminal neuralgia have no overt cause for the disorder. When there is a tumor or blood vessel creating undue pressure on the nerve a surgiclal approach is usually corrective but the central sensitization may remain. This article postulates that time is of the essence and the longer the pain persists the more likely that brain plasticity will lead to long term central sensitization. Decompression should be done ASAP according to that line of thought.
The majority of patients diagnosed with trigeminal neuralgia do not have tumor or blood vessels encroaching on the trigeminal nerve. It is well known that treatment of TMJ disorders is highly effective in reducing pain and that Neuromuscular Dentistry has been shown to be "overwhelmingly successful" according to Dr Barry Cooper and published in Cranio Journal.
The same rationale that says the key to preventing central sensitiztion is to address the problem as soon as possible also holds true with neuromuscular problems affecting the jaws, bite, jaw muscles and TMJ (TM Joints).
The effects of pressure on the trigeminal nerve are periferrral effects (noxius input) afecting the CNS. Neuromuscular bite problems are also noxious input from the periferal nervous system.
A second article in Medical Hypothesis "Migraine, neuropathic pain and nociceptive pain: towards a unifying concept." brought this to light and pushed the unifying concept of mifgraine and neuropathic pain. The basic concepts are identical. Correction of noxious input is the key to treating the pain and preventing central sensitization. This is exactly the concepts behind Neuromuscular Dentistry.
This is also explained in an excellent article on Myofascial pain and TMD published in J Pain. 2009 Nov;10(11):1170-8 (see PubMed Abstract below)"Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing." that is interesting because it looks at a group of 20-28 year old patients with myofascial pain, TMD and central sensitization. This group of patients definitively show how periferral pain manifestations induce central sensitization. The time to intervene with neuromuscular dentistry is at an earlier stage before central sensitization occurs.
There is also a concern about the quality of sleep as TMD patients have a much higher incidence of sleep apnea which I believe predisposes patients to central nervous system changes. Migraines, Chronic Daily Headaches, Tension-Type headaches and TMD are all directly effected by the trigeminal nerve and the trigeminovascular connection. Neuromuscular Dentistry can effect the central nervous system by changing the quality of neuro input.
Med Hypotheses. 2010 Feb 19. [Epub ahead of print]
Atypical trigeminal neuralgia: A consequence of central sensitization?
Hu WH, Zhang K, Zhang JG.
Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
Trigeminal neuralgia (TN) is characterized by sudden, recurrent, usually unilateral, severe brief stabbing pains in the distribution of trigeminal nerve. Although it is widely accepted that blood vessel or tumor compression contributes to paroxysms of TN, the pathogenesis of persistent background pain in atypical TN patient is unclear. Central sensitization is pain hypersensitivity caused by central neural plasticity. It is responsible for many temporal and symptomatic features of acute and chronic pain. We hypothesize that central sensitization might account for some symptoms of atypical TN. Based on this hypothesis, we postulate that early medical intervention predicts good outcomes in TN and medicines which are effective on central sensitization may be potential agents for the treatment of atypical TN. Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID: 20172658 [PubMed - as supplied by publisher]
Med Hypotheses. 2010 Feb;74(2):225-31. Epub 2009 Sep 17.
Migraine, neuropathic pain and nociceptive pain: towards a unifying concept.
Chakravarty A, Sen A.
Department of Neurology, Vivekananda Institute of Medical Sciences, Calcutta, India. saschakra@yahoo.com
Migraine, neuropathic pain and nociceptive pain are the three commonest pain syndromes affecting human. In the present article, we first present the salient features of the pathophysiology of the three conditions particularly highlighting the core features that are similar in the three conditions. We argue on the validity of the prevailing concept that maintenance of structural integrity of the nervous system differentiates nociceptive pain from neuropathic pain and point out that the fundamental pathophysiology of lasting nociceptive pain (like cancer pain) and neuropathic pain (like nerve injury pain) is essentially same. Migraine pathophysiology is complex and complicated by two opposing views on site of migraine pain generation - peripheral versus central. We hypothesize that this dichotomy has resulted from focusing on two different sites on a single, somewhat complicated, pain mediating circuitry from the peripheral meningeal and vascular structures through several cell stations in the brain stem and thalamus up to the sensory cortical matrix. At the end, we suggest that fundamentally all the three pain syndromes referred to in the article share a common pathophysiological mechanism, namely peripheral pain perception, peripheral sensitization at dorsal root ganglion or its intracranial counterpart (like trigeminal ganglion) and central sensitization at the spinal cord (dorsal horn for somatic pain), brain stem nuclei and thalamus before final pain perception at the sensory cortical matrix.
PMID: 19765908 [PubMed - in process]
that cause central sensitization and pain.
J Pain. 2009 Nov;10(11):1170-8. Epub 2009 Jul 9.
Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing.
.
Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P.
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. cesar.fernandez@urjc.es
Our aim was to investigate bilateral, widespread pressure-pain hypersensitivity in nerve, muscle, and joint tissues in women with myofascial temporomandibular disorders (TMD) without concomitant comorbid conditions. Twenty women with myofascial TMD (aged 20 to 28 years old), and 20 healthy matched women (aged 20 to 29 years), were recruited. Pressure-pain thresholds (PPT) were bilaterally assessed over supra-orbital (V1), infra-orbital (V2), mental (V3) nerves, median (C5), radial (C6) and ulnar (C7) nerve trunks, the C5-C6 zygapophyseal joint, the lateral pole of the temporo mandibular joint (TMJ), and the tibialis anterior muscle in a blinded design. The results showed that PPTs were significantly decreased bilaterally over the supra-orbital, infra-orbital, and mental nerves, median, ulnar, and radial nerve trunks, the lateral pole of the TMJ, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with myofascial TMD as compared to healthy controls (all sites: P < .001). There were no significant differences in the magnitude of PPT decreases between the trigeminal and extratrigeminal test sites. PPT over the mental nerve, the TMJ, C5-C6 zygapophyseal joint and tibialis anterior muscle were negatively correlated to both duration of pain symptoms and TMD pain intensity (P < .05). Our findings revealed bilateral, widespread pressure hypersensitivity in women presenting with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD women. PERSPECTIVE: This article reveals the presence of bilateral and widespread pressure-pain hypersensitivity in women with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD. This finding has implications for development of management strategies.
PMID: 19592309 [PubMed - indexed for MEDLINE]
Many patients who have trigeminal neuralgia have no overt cause for the disorder. When there is a tumor or blood vessel creating undue pressure on the nerve a surgiclal approach is usually corrective but the central sensitization may remain. This article postulates that time is of the essence and the longer the pain persists the more likely that brain plasticity will lead to long term central sensitization. Decompression should be done ASAP according to that line of thought.
The majority of patients diagnosed with trigeminal neuralgia do not have tumor or blood vessels encroaching on the trigeminal nerve. It is well known that treatment of TMJ disorders is highly effective in reducing pain and that Neuromuscular Dentistry has been shown to be "overwhelmingly successful" according to Dr Barry Cooper and published in Cranio Journal.
The same rationale that says the key to preventing central sensitiztion is to address the problem as soon as possible also holds true with neuromuscular problems affecting the jaws, bite, jaw muscles and TMJ (TM Joints).
The effects of pressure on the trigeminal nerve are periferrral effects (noxius input) afecting the CNS. Neuromuscular bite problems are also noxious input from the periferal nervous system.
A second article in Medical Hypothesis "Migraine, neuropathic pain and nociceptive pain: towards a unifying concept." brought this to light and pushed the unifying concept of mifgraine and neuropathic pain. The basic concepts are identical. Correction of noxious input is the key to treating the pain and preventing central sensitization. This is exactly the concepts behind Neuromuscular Dentistry.
This is also explained in an excellent article on Myofascial pain and TMD published in J Pain. 2009 Nov;10(11):1170-8 (see PubMed Abstract below)"Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing." that is interesting because it looks at a group of 20-28 year old patients with myofascial pain, TMD and central sensitization. This group of patients definitively show how periferral pain manifestations induce central sensitization. The time to intervene with neuromuscular dentistry is at an earlier stage before central sensitization occurs.
There is also a concern about the quality of sleep as TMD patients have a much higher incidence of sleep apnea which I believe predisposes patients to central nervous system changes. Migraines, Chronic Daily Headaches, Tension-Type headaches and TMD are all directly effected by the trigeminal nerve and the trigeminovascular connection. Neuromuscular Dentistry can effect the central nervous system by changing the quality of neuro input.
Med Hypotheses. 2010 Feb 19. [Epub ahead of print]
Atypical trigeminal neuralgia: A consequence of central sensitization?
Hu WH, Zhang K, Zhang JG.
Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
Trigeminal neuralgia (TN) is characterized by sudden, recurrent, usually unilateral, severe brief stabbing pains in the distribution of trigeminal nerve. Although it is widely accepted that blood vessel or tumor compression contributes to paroxysms of TN, the pathogenesis of persistent background pain in atypical TN patient is unclear. Central sensitization is pain hypersensitivity caused by central neural plasticity. It is responsible for many temporal and symptomatic features of acute and chronic pain. We hypothesize that central sensitization might account for some symptoms of atypical TN. Based on this hypothesis, we postulate that early medical intervention predicts good outcomes in TN and medicines which are effective on central sensitization may be potential agents for the treatment of atypical TN. Copyright © 2010 Elsevier Ltd. All rights reserved.
PMID: 20172658 [PubMed - as supplied by publisher]
Med Hypotheses. 2010 Feb;74(2):225-31. Epub 2009 Sep 17.
Migraine, neuropathic pain and nociceptive pain: towards a unifying concept.
Chakravarty A, Sen A.
Department of Neurology, Vivekananda Institute of Medical Sciences, Calcutta, India. saschakra@yahoo.com
Migraine, neuropathic pain and nociceptive pain are the three commonest pain syndromes affecting human. In the present article, we first present the salient features of the pathophysiology of the three conditions particularly highlighting the core features that are similar in the three conditions. We argue on the validity of the prevailing concept that maintenance of structural integrity of the nervous system differentiates nociceptive pain from neuropathic pain and point out that the fundamental pathophysiology of lasting nociceptive pain (like cancer pain) and neuropathic pain (like nerve injury pain) is essentially same. Migraine pathophysiology is complex and complicated by two opposing views on site of migraine pain generation - peripheral versus central. We hypothesize that this dichotomy has resulted from focusing on two different sites on a single, somewhat complicated, pain mediating circuitry from the peripheral meningeal and vascular structures through several cell stations in the brain stem and thalamus up to the sensory cortical matrix. At the end, we suggest that fundamentally all the three pain syndromes referred to in the article share a common pathophysiological mechanism, namely peripheral pain perception, peripheral sensitization at dorsal root ganglion or its intracranial counterpart (like trigeminal ganglion) and central sensitization at the spinal cord (dorsal horn for somatic pain), brain stem nuclei and thalamus before final pain perception at the sensory cortical matrix.
PMID: 19765908 [PubMed - in process]
that cause central sensitization and pain.
J Pain. 2009 Nov;10(11):1170-8. Epub 2009 Jul 9.
Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing.
.
Fernández-de-las-Peñas C, Galán-del-Río F, Fernández-Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P.
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain. cesar.fernandez@urjc.es
Our aim was to investigate bilateral, widespread pressure-pain hypersensitivity in nerve, muscle, and joint tissues in women with myofascial temporomandibular disorders (TMD) without concomitant comorbid conditions. Twenty women with myofascial TMD (aged 20 to 28 years old), and 20 healthy matched women (aged 20 to 29 years), were recruited. Pressure-pain thresholds (PPT) were bilaterally assessed over supra-orbital (V1), infra-orbital (V2), mental (V3) nerves, median (C5), radial (C6) and ulnar (C7) nerve trunks, the C5-C6 zygapophyseal joint, the lateral pole of the temporo mandibular joint (TMJ), and the tibialis anterior muscle in a blinded design. The results showed that PPTs were significantly decreased bilaterally over the supra-orbital, infra-orbital, and mental nerves, median, ulnar, and radial nerve trunks, the lateral pole of the TMJ, the C5-C6 zygapophyseal joint, and the tibialis anterior muscle in patients with myofascial TMD as compared to healthy controls (all sites: P < .001). There were no significant differences in the magnitude of PPT decreases between the trigeminal and extratrigeminal test sites. PPT over the mental nerve, the TMJ, C5-C6 zygapophyseal joint and tibialis anterior muscle were negatively correlated to both duration of pain symptoms and TMD pain intensity (P < .05). Our findings revealed bilateral, widespread pressure hypersensitivity in women presenting with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD women. PERSPECTIVE: This article reveals the presence of bilateral and widespread pressure-pain hypersensitivity in women with myofascial TMD, suggesting that widespread central sensitization is involved in myofascial TMD. This finding has implications for development of management strategies.
PMID: 19592309 [PubMed - indexed for MEDLINE]
Monday, February 22, 2010
Calcitonin gene-related peptide involved in migraine from trigeminovascular system
A recent article points to the use of CRCP (Calcitonin gene-related peptide) antagonists to treat migraines. Levels of CGRP rise during migraine and experimentally injecting IV CRCP can provoke migraine. Two CGRP antagonists are being tested inthe study from Acta Neurol Belg. 2009 Dec;109(4):252-61.
CGRP is produced by the trigeminovascular system. Many patients who undergo treatment with a diagnostic neuromuscular orthotic frequently see migraines decreased and/or eliminated. A future area of study would be does Neuromuscular Dentistry work by decreasing CGRP release from the trigeminal nerve. I consider most problems to be input/output errors of the trigeminal nervous system. Do noxious inputs from the teeth, jaw muscles, jaw joints, and periodontal ligament cause surges in CRGP in susceptible individuals causing migraine.
PubMed abstract
Acta Neurol Belg. 2009 Dec;109(4):252-61.
CGRP antagonists: hope for a new era in acute migraine treatment.
Schelstraete C, Paemeleire K.
Department of Neurology, Ghent University Hospital, Ghent, Belgium.
Calcitonin gene-related peptide (CGRP) has a widespread distribution throughout the trigeminovascular system and other brain areas involved in migraine pathogenesis. Serum levels of CGRP are elevated during the migraine attack and return to normal with alleviation of pain. Intravenous injection of CGRP in migraineurs results in delayed headache similar to migraine. Since CGRP receptor antagonists lack direct vasoconstrictor activity, this therapeutic approach may offer advantages over the current mainstay of specific acute migraine treatment with 5-HT1B/1D receptor agonists (triptans), contra-indicated in patients with underlying cardiovascular disease. Intravenous BIBN4096BS (olcegepant) and oral MK-0974 (telcagepant), two CGRP-receptor antagonists, were safe and effective in the treatment of migraine attacks in Phase I and II trials. In a Phase III clinical trial, the efficacy of telcagepant 300 mg was comparable to that of zolmitriptan 5 mg. We intend to review the rationale for the use of CGRP-receptor antagonists, and to outline current developments and future perspectives.
CGRP is produced by the trigeminovascular system. Many patients who undergo treatment with a diagnostic neuromuscular orthotic frequently see migraines decreased and/or eliminated. A future area of study would be does Neuromuscular Dentistry work by decreasing CGRP release from the trigeminal nerve. I consider most problems to be input/output errors of the trigeminal nervous system. Do noxious inputs from the teeth, jaw muscles, jaw joints, and periodontal ligament cause surges in CRGP in susceptible individuals causing migraine.
PubMed abstract
Acta Neurol Belg. 2009 Dec;109(4):252-61.
CGRP antagonists: hope for a new era in acute migraine treatment.
Schelstraete C, Paemeleire K.
Department of Neurology, Ghent University Hospital, Ghent, Belgium.
Calcitonin gene-related peptide (CGRP) has a widespread distribution throughout the trigeminovascular system and other brain areas involved in migraine pathogenesis. Serum levels of CGRP are elevated during the migraine attack and return to normal with alleviation of pain. Intravenous injection of CGRP in migraineurs results in delayed headache similar to migraine. Since CGRP receptor antagonists lack direct vasoconstrictor activity, this therapeutic approach may offer advantages over the current mainstay of specific acute migraine treatment with 5-HT1B/1D receptor agonists (triptans), contra-indicated in patients with underlying cardiovascular disease. Intravenous BIBN4096BS (olcegepant) and oral MK-0974 (telcagepant), two CGRP-receptor antagonists, were safe and effective in the treatment of migraine attacks in Phase I and II trials. In a Phase III clinical trial, the efficacy of telcagepant 300 mg was comparable to that of zolmitriptan 5 mg. We intend to review the rationale for the use of CGRP-receptor antagonists, and to outline current developments and future perspectives.
Sunday, February 21, 2010
Throat Pain: Frequently can be hard to diagnose and misdiagnosis is common.
An article (PubMed abstract below) in Janury "CRANIO journal" by Dr Wes Shankland dicusses patients with anterior throat pain. These patients have frequently seen numerous physicians and had multiple digagnostic tests and frequently ineffective treatment. There are five syndromes that frequently cause this type of problems. The five disorders are, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome.
Ernest syndrome and Ernst Syndrome are caused by calcification of stylohyoid or stylomandibular ligaments that is frequently diagnosed by panoramic radiographs and palpation of the ligaments. There are numerous cases of throat pain being referred from various muscless but Dr Shankland points to the Superior Pharyngeal constictor syndrome.
According to an article from Tulane (see PUBMED abstract below) a diagnosis of Eagle's syndrome can be difficult to make. The diagnosis is infrequent and the symptoms vary widely.
An excellent description of Eagles Synrome can be found in "South Med J. 1998 Jan;91(1):43." (see PubMed abstract below) "Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear". Some of the symptoms of Eagle's Syndrome include:
Pain on turning head
Pain associated with tongue protrusion
Cough without sputum
Voice changes
Symptoms of Sinusitis that do not respon to treatment
Dizziness and/or feelings of disequilibrium, Vertigo
Bloodshot eyes
Throat pain,Throat discomfort Throat soreness or Foreign body sensation in throat
Facial pain
Difficulty swallowing or Dysphagia
Disturbed sense of taste
Headache especially if associated with swallowing
Sensation of excessive salivation
Swallowing difficulty, throat pain associated with swallowing
Pain on opening mouth
Bafaqeeh subclassified Eagle's syndrome into two different types: its classic form and an entity he called styloid-carotid artery syndrome. Symptoms include neurological and vascular problems with at least one report of blindness. The management of styloid-carotid artery syndrome include sagittal CT angiography and/or intraoperative neurophysiologic monitoring, and a transcervical approach to resection.
Many cases of undiagnosed throat pain respond well to neuromucular diagnostic orthotics. When the orthotic and/or trigger point injections do not relieve the pain these other conditions must be explored.
Cranio. 2010 Jan;28(1):50-9.
Anterior throat pain syndromes: causes for undiagnosed craniofacial pain.
Shankland WE 2nd.
TMJ & Facial Pain Center, Westerville, Columbus, Ohio, USA. drwes@drshankland.com
It is not uncommon for practitioners who treat craniofacial pain to see patients with undiagnosed throat and submandibular pain. Usually, these patients will already have been seen by their primary care physician and frequently, several others doctors including otolaryngologists, oral and maxillofacial surgeons, and even neurologists. Far too often these patients have three common features: 1. they have endured multiple expensive diagnostic tests; 2. they have received treatment of multiple courses of antibiotics; and 3. no specific diagnosis for their pain complaints has been determined and their pain persists. In this article, five disorders, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome are briefly described. All five produce common symptoms, making diagnosis difficult, which is often followed by ineffective or no treatment being provided to the patient. Diagnostic criteria and suggested treatment modalities are also presented.
PMID: 20158009 [PubMed - in process]
J La State Med Soc. 1992 Aug;144(8):343-5.
Eagle's syndrome: the Ochsner experience.
Weiss LS, Butcher RB, White JA.
Dept of Otolaryngology-Head & Neck Surgery, Tulane University Medical Center, New Orleans.
Eagle fully described the syndrome that bears his name in 1948. He noted that the typical patient had undergone tonsillectomy in the past. Although reported in the literature, the carotid artery syndrome is frequently overlooked in patients manifesting craniofacial or pharyngeal pain but who have not undergone tonsillectomy. Cases representative of the variety of patients with Eagle's syndrome treated at the Ochsner Clinic Department of Otolaryngology are presented. The diversity of symptoms and its rather uncommon occurrence often make the diagnosis of Eagle's syndrome elusive. The anatomy and embryology of the stylohyoid complex is discussed, as well as the symptoms, differential diagnosis, workup, and treatment of Eagle's syndrome. We hope to refamiliarize the clinician with this condition in order that it be considered in the assessment of patients with craniofacial pain.
PMID: 1453090 [PubMed - indexed for MEDLINE]
South Med J. 1997 Mar;90(3):331-4.
Eagle's syndrome (elongated styloid process)
Balbuena L Jr, Hayes D, Ramirez SG, Johnson R.
Otolaryngology-Head and Neck Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Tex, USA.
Comment in:
South Med J. 1998 Jan;91(1):43.
Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In adults, the styloid process is approximately 2.5 cm long, and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa. It may develop inflammatory changes or impinge on the adjacent arteries or sensory nerve endings, leading to the symptoms described. Diagnosis can usually be made on physical examination by digital palpation of the styloid process in the tonsillar fossa, which exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into the tonsillar fossa is highly suggestive of this diagnosis. Radiographic workup should include anterior-posterior and lateral skull films. The treatment of Eagle's syndrome is primarily surgical. The styloid process can be shortened through an intraoral or external approach. We present two cases and review the literature.
PMID: 9076308 [PubMed - indexed for MEDLINE]
Ernest syndrome and Ernst Syndrome are caused by calcification of stylohyoid or stylomandibular ligaments that is frequently diagnosed by panoramic radiographs and palpation of the ligaments. There are numerous cases of throat pain being referred from various muscless but Dr Shankland points to the Superior Pharyngeal constictor syndrome.
According to an article from Tulane (see PUBMED abstract below) a diagnosis of Eagle's syndrome can be difficult to make. The diagnosis is infrequent and the symptoms vary widely.
An excellent description of Eagles Synrome can be found in "South Med J. 1998 Jan;91(1):43." (see PubMed abstract below) "Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear". Some of the symptoms of Eagle's Syndrome include:
Pain on turning head
Pain associated with tongue protrusion
Cough without sputum
Voice changes
Symptoms of Sinusitis that do not respon to treatment
Dizziness and/or feelings of disequilibrium, Vertigo
Bloodshot eyes
Throat pain,Throat discomfort Throat soreness or Foreign body sensation in throat
Facial pain
Difficulty swallowing or Dysphagia
Disturbed sense of taste
Headache especially if associated with swallowing
Sensation of excessive salivation
Swallowing difficulty, throat pain associated with swallowing
Pain on opening mouth
Bafaqeeh subclassified Eagle's syndrome into two different types: its classic form and an entity he called styloid-carotid artery syndrome. Symptoms include neurological and vascular problems with at least one report of blindness. The management of styloid-carotid artery syndrome include sagittal CT angiography and/or intraoperative neurophysiologic monitoring, and a transcervical approach to resection.
Many cases of undiagnosed throat pain respond well to neuromucular diagnostic orthotics. When the orthotic and/or trigger point injections do not relieve the pain these other conditions must be explored.
Cranio. 2010 Jan;28(1):50-9.
Anterior throat pain syndromes: causes for undiagnosed craniofacial pain.
Shankland WE 2nd.
TMJ & Facial Pain Center, Westerville, Columbus, Ohio, USA. drwes@drshankland.com
It is not uncommon for practitioners who treat craniofacial pain to see patients with undiagnosed throat and submandibular pain. Usually, these patients will already have been seen by their primary care physician and frequently, several others doctors including otolaryngologists, oral and maxillofacial surgeons, and even neurologists. Far too often these patients have three common features: 1. they have endured multiple expensive diagnostic tests; 2. they have received treatment of multiple courses of antibiotics; and 3. no specific diagnosis for their pain complaints has been determined and their pain persists. In this article, five disorders, Ernest syndrome, Eagle's syndrome, carotid artery syndrome, hyoid bone syndrome and superior pharyngeal constrictor syndrome are briefly described. All five produce common symptoms, making diagnosis difficult, which is often followed by ineffective or no treatment being provided to the patient. Diagnostic criteria and suggested treatment modalities are also presented.
PMID: 20158009 [PubMed - in process]
J La State Med Soc. 1992 Aug;144(8):343-5.
Eagle's syndrome: the Ochsner experience.
Weiss LS, Butcher RB, White JA.
Dept of Otolaryngology-Head & Neck Surgery, Tulane University Medical Center, New Orleans.
Eagle fully described the syndrome that bears his name in 1948. He noted that the typical patient had undergone tonsillectomy in the past. Although reported in the literature, the carotid artery syndrome is frequently overlooked in patients manifesting craniofacial or pharyngeal pain but who have not undergone tonsillectomy. Cases representative of the variety of patients with Eagle's syndrome treated at the Ochsner Clinic Department of Otolaryngology are presented. The diversity of symptoms and its rather uncommon occurrence often make the diagnosis of Eagle's syndrome elusive. The anatomy and embryology of the stylohyoid complex is discussed, as well as the symptoms, differential diagnosis, workup, and treatment of Eagle's syndrome. We hope to refamiliarize the clinician with this condition in order that it be considered in the assessment of patients with craniofacial pain.
PMID: 1453090 [PubMed - indexed for MEDLINE]
South Med J. 1997 Mar;90(3):331-4.
Eagle's syndrome (elongated styloid process)
Balbuena L Jr, Hayes D, Ramirez SG, Johnson R.
Otolaryngology-Head and Neck Surgery Service, Brooke Army Medical Center, Fort Sam Houston, Tex, USA.
Comment in:
South Med J. 1998 Jan;91(1):43.
Eagle's syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Additional symptoms may include neck or throat pain with radiation to the ipsilateral ear. In adults, the styloid process is approximately 2.5 cm long, and its tip is located between the external and internal carotid arteries, just lateral to the tonsillar fossa. It may develop inflammatory changes or impinge on the adjacent arteries or sensory nerve endings, leading to the symptoms described. Diagnosis can usually be made on physical examination by digital palpation of the styloid process in the tonsillar fossa, which exacerbates the pain. In addition, relief of symptoms with injection of an anesthetic solution into the tonsillar fossa is highly suggestive of this diagnosis. Radiographic workup should include anterior-posterior and lateral skull films. The treatment of Eagle's syndrome is primarily surgical. The styloid process can be shortened through an intraoral or external approach. We present two cases and review the literature.
PMID: 9076308 [PubMed - indexed for MEDLINE]
FACIAL PAIN AND NEUROMUSCULAR DENTISTRY
The diagnosis of facial pain is frequently not called headache pain and often receives a wrong diagnosis. Possible causes of facial pain are TMJ disordrs, trigeinal neuralgia, parotid gland disorders, masticatory muscle pain or pain referred from the cervical an shoulder reasons. Facial pain may resolve easily with neuromuscular dental treatment but it is important to rule out pain of organic nature.
Facial pain and sinus pain are frequently different terms patients use to describe pain referred from muscles which are the easiet pain a neuromuscular dentist treats.
When there is neuralgia pain it is usually sharp, sudden and lancinating and very emotionally charge. I have had patients with trigeminal neuralgia that will protect their trigger area no matter what. It is important to identify triggers that set off this type of excruciating pain. I have seen many patients over the years with neuralgia like pains. Some resonded well to neuromuscular dental treatment immediately while others responded to trigger point injections.
Frequently the area must be calmed down by drug therapy or counter irritants like capascin cream before attempting to place a patient on a TENS unit.
Facial pain and sinus pain are frequently different terms patients use to describe pain referred from muscles which are the easiet pain a neuromuscular dentist treats.
When there is neuralgia pain it is usually sharp, sudden and lancinating and very emotionally charge. I have had patients with trigeminal neuralgia that will protect their trigger area no matter what. It is important to identify triggers that set off this type of excruciating pain. I have seen many patients over the years with neuralgia like pains. Some resonded well to neuromuscular dental treatment immediately while others responded to trigger point injections.
Frequently the area must be calmed down by drug therapy or counter irritants like capascin cream before attempting to place a patient on a TENS unit.
Thursday, February 18, 2010
Wednesday, February 17, 2010
Sleep and Headaches linked in article in Current Treatment Options in Neurology
An article by Jeanetta C. Rains1 and J. Steven Poceta gives an opinion paper on the relation of sleep to headache. They feel that headache is linked to a wide variety of sleep disorders that may impact treatment results and headache management.
They believe that after standard diagnosis of headache a sleep history should be collected according to headache problems. Initally they state that you should rule out sleep apnea in patients with headaches on awakening. I agree and have frequently said that the two main causes of morning headaches are TMJ disorders, Sleep Apnea and Bruxing. The NHLBI of the NIH published a report "Cardiovascular and Sleep Related Consequences of Temoporomandibular Disorders" Morning headaches can also be caused by jaw clenching but newer evidence relates clenching to awakenings by sleep disordered breathing.
They believe that cluster headaches, chronic migraine and chronic tension-type headache should have sleep apnea ruled out as a cause. I believe that looking at the neuromuscular system to evaluate patients for TMJ disorders, muscle disorders and trigeminal nervous disorders related to the bite is also essential. Neuromuscular Dentistry is a method that has been shown to be "overwhelmingly successful according to Dr Barry Cooper and as published in Cranio Journal.
If there are signs and symptoms of sleep apnea they Rx polysomnography and treatment with CPAP. While CPAP is effective I feel patients with headaches and sleep apnea would be much better served by combining treatments by utilizing an intra-oral apnea appliance that will also help decrease headaches of trigeminal orgin, or almost all types of headaches. Studies with oral appliances for headache treatment show a minimal 50% improvement in the majority of patients. They do not advocate suspending regular headache treatment when treating apnea but many of the patients treated with oral appliances report complete relief of headaches. CPAP can also be effective but 60% of patients reject it and it causes negative side effects in a significant number of patients who use it leading to discontinuation of CPAP and/or poor compliance.
The authors stated that use of oral appliance, surgery and weight loss are untested displaying a suprising amout of ignorance about the current parameters of care for treating sleep apnea that considers oral appliances to be a first line of treatment for mild to moderate sleep apnea and an alternative for severe apnea when CPAP is not tolerated. The percentage of patients that do not tolerate CPAP is the same for mild, moderate and severe sleep apnea patients.
The authors reported "patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients." They did not specify it is was sleep onset insomnia or maintenance of sleep insomnia.
The authors also stated "All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management."
I believe it in incumbent on physicians and dentists treating headaches be acutely aware of the effect of sleep disorders on headache.
They should also be aware that psychiatric disorders and depression frequently occur in chronic pain patients as a direct result of the chronic pain.
Treatment of sleep disorders and headache with a combination of a neuromuscular daytime orthotic and a n intraoral sleep apnea appliance or use of a 24 hour orthotic is "overwhelming successful" as published in Cranio Journal.
They believe that after standard diagnosis of headache a sleep history should be collected according to headache problems. Initally they state that you should rule out sleep apnea in patients with headaches on awakening. I agree and have frequently said that the two main causes of morning headaches are TMJ disorders, Sleep Apnea and Bruxing. The NHLBI of the NIH published a report "Cardiovascular and Sleep Related Consequences of Temoporomandibular Disorders" Morning headaches can also be caused by jaw clenching but newer evidence relates clenching to awakenings by sleep disordered breathing.
They believe that cluster headaches, chronic migraine and chronic tension-type headache should have sleep apnea ruled out as a cause. I believe that looking at the neuromuscular system to evaluate patients for TMJ disorders, muscle disorders and trigeminal nervous disorders related to the bite is also essential. Neuromuscular Dentistry is a method that has been shown to be "overwhelmingly successful according to Dr Barry Cooper and as published in Cranio Journal.
If there are signs and symptoms of sleep apnea they Rx polysomnography and treatment with CPAP. While CPAP is effective I feel patients with headaches and sleep apnea would be much better served by combining treatments by utilizing an intra-oral apnea appliance that will also help decrease headaches of trigeminal orgin, or almost all types of headaches. Studies with oral appliances for headache treatment show a minimal 50% improvement in the majority of patients. They do not advocate suspending regular headache treatment when treating apnea but many of the patients treated with oral appliances report complete relief of headaches. CPAP can also be effective but 60% of patients reject it and it causes negative side effects in a significant number of patients who use it leading to discontinuation of CPAP and/or poor compliance.
The authors stated that use of oral appliance, surgery and weight loss are untested displaying a suprising amout of ignorance about the current parameters of care for treating sleep apnea that considers oral appliances to be a first line of treatment for mild to moderate sleep apnea and an alternative for severe apnea when CPAP is not tolerated. The percentage of patients that do not tolerate CPAP is the same for mild, moderate and severe sleep apnea patients.
The authors reported "patients with migraine and tension-type headache, insomnia is the most common sleep complaint, reported by one half to two thirds of clinic patients." They did not specify it is was sleep onset insomnia or maintenance of sleep insomnia.
The authors also stated "All headache patients, particularly those with episodic migraine and tension-type headaches, may benefit from inclusion of sleep variables in trigger management."
I believe it in incumbent on physicians and dentists treating headaches be acutely aware of the effect of sleep disorders on headache.
They should also be aware that psychiatric disorders and depression frequently occur in chronic pain patients as a direct result of the chronic pain.
Treatment of sleep disorders and headache with a combination of a neuromuscular daytime orthotic and a n intraoral sleep apnea appliance or use of a 24 hour orthotic is "overwhelming successful" as published in Cranio Journal.
Sleep and Headaches linked in article in Current Treatment Options in Neurology
Jeanetta C. Rains1 and J. Steven Poceta2
Current Treatment Options in Neurology
(1) Center for Sleep Evaluation, Elliot Hospital, One Elliot Way, Manchester, NH 03103, USA
(2) Scripps Clinic Sleep Center and Division of Nematology, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA
Published online: 14 February 2010
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.
--------------------------------------------------------------------------------
Jeanetta C. Rains
Email: jrains@elliot-hs.or
Current Treatment Options in Neurology
(1) Center for Sleep Evaluation, Elliot Hospital, One Elliot Way, Manchester, NH 03103, USA
(2) Scripps Clinic Sleep Center and Division of Nematology, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA
Published online: 14 February 2010
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.
--------------------------------------------------------------------------------
Jeanetta C. Rains
Email: jrains@elliot-hs.or
Monday, February 15, 2010
Facial Pain and Headache: Incidence of Facial Pain
A recent article in the Journal Pain looked at incidence of facial pain in the Netherlands. The authors wanted to " The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH)"
Trigeminal Neuralgia and Cluster Headaches were the most common types and both increased with age. This study found that facial pain was rare but more common than expected prior to the study. The trigeminal nerve is frequently a culprit in many types of pain disorders. Many, but not all patients with trigeminal neuralgia diagnosis will respond positively to neuromuscular treatment.
My take on this is a little different because I frequently see patients who complain of sinus pain, tooth pain eye pain while pointing to painful areas. Thsi study would have ignored thos findings. Over the years I frequently see patients that have been given a diagnosis of a disorder neuromuscular dentistry can't treat yet they get better with an orthotic. This does not mean the orthotic can treat those conditions and often just points out a misdiagnosis. I have had patients diagnosed with MS whose symptoms disappeared with my treatment. That does not mean I treated the MS, it may just mean that the diagnosis was incorrect.
There is no harm in a second or third opinion.
Pain. 2009 Dec 15;147(1-3):122-7. Epub 2009 Sep 26.
Incidence of facial pain in the general population.
Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC.
Dept. of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands. skoop29@gmail.com
Facial pain has a considerable impact on quality of life. Accurate incidence estimates in the general population are scant. The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH) in the Netherlands. In the population-based Integrated Primary Care Information (IPCI) medical record database potential facial pain cases were identified from codes and narratives. Two medical doctors reviewed medical records, questionnaires from general practitioners and specialist letters using criteria of the International Association for the Study of Pain. A pain specialist arbitrated if necessary and a random sample of all cases was evaluated by a neurologist. The date of onset was defined as date of first specific symptoms. The IR was calculated per 100,000PY. Three hundred and sixty-two incident cases were ascertained. The overall IR [95% confidence interval] was 38.7 [34.9-42.9]. It was more common among women compared to men. Trigeminal neuralgia and cluster headache were the most common forms among the studied diseases. Paroxysmal hemicrania and glossopharyngeal neuralgia were among the rarer syndromes. The IR increased with age for all diseases except CH and ON, peaking in the 4th and 7th decade, respectively. Postherpetic neuralgia, CH and LoN were more common in men than women. From this we can conclude that facial pain is relatively rare, although more common than estimated previously based on hospital data.
PMID: 19783099 [PubMed - in process]
Trigeminal Neuralgia and Cluster Headaches were the most common types and both increased with age. This study found that facial pain was rare but more common than expected prior to the study. The trigeminal nerve is frequently a culprit in many types of pain disorders. Many, but not all patients with trigeminal neuralgia diagnosis will respond positively to neuromuscular treatment.
My take on this is a little different because I frequently see patients who complain of sinus pain, tooth pain eye pain while pointing to painful areas. Thsi study would have ignored thos findings. Over the years I frequently see patients that have been given a diagnosis of a disorder neuromuscular dentistry can't treat yet they get better with an orthotic. This does not mean the orthotic can treat those conditions and often just points out a misdiagnosis. I have had patients diagnosed with MS whose symptoms disappeared with my treatment. That does not mean I treated the MS, it may just mean that the diagnosis was incorrect.
There is no harm in a second or third opinion.
Pain. 2009 Dec 15;147(1-3):122-7. Epub 2009 Sep 26.
Incidence of facial pain in the general population.
Koopman JS, Dieleman JP, Huygen FJ, de Mos M, Martin CG, Sturkenboom MC.
Dept. of Medical Informatics, Erasmus MC, Rotterdam, The Netherlands. skoop29@gmail.com
Facial pain has a considerable impact on quality of life. Accurate incidence estimates in the general population are scant. The aim was therefore to estimate the incidence rate (IR) of trigeminal neuralgia (TGN), postherpetic neuralgia (PHN), cluster headache (CH), occipital neuralgia (ON), local neuralgia (LoN), atypical facial pain (AFP), glossopharyngeal neuralgia (GPN) and paroxysmal hemicrania (PH) in the Netherlands. In the population-based Integrated Primary Care Information (IPCI) medical record database potential facial pain cases were identified from codes and narratives. Two medical doctors reviewed medical records, questionnaires from general practitioners and specialist letters using criteria of the International Association for the Study of Pain. A pain specialist arbitrated if necessary and a random sample of all cases was evaluated by a neurologist. The date of onset was defined as date of first specific symptoms. The IR was calculated per 100,000PY. Three hundred and sixty-two incident cases were ascertained. The overall IR [95% confidence interval] was 38.7 [34.9-42.9]. It was more common among women compared to men. Trigeminal neuralgia and cluster headache were the most common forms among the studied diseases. Paroxysmal hemicrania and glossopharyngeal neuralgia were among the rarer syndromes. The IR increased with age for all diseases except CH and ON, peaking in the 4th and 7th decade, respectively. Postherpetic neuralgia, CH and LoN were more common in men than women. From this we can conclude that facial pain is relatively rare, although more common than estimated previously based on hospital data.
PMID: 19783099 [PubMed - in process]
Temporal Arteritis misdiagnosed as migraine leading to tragic conditions for patient
Drug herapy always carries some risks. The following abstract details how a patient was treated for migraines with ergotamine. The patient was suffering from tiredness and weight loss and fever after a single dose of ergotamine. A second dose led to tongue necrosis (necrosis means death of the tissue) The authors felt that the necrosis of the tongue could have been the result of undiagnosed temporal arteritis a condition that can also cause blindness. A clinical sign of temporal arteritis is an elevated sed rate.
Ergotamine is a well known drug in migraine treatment and this is an unusual case. With neuromuscular dentistry we are always on the look out for red herrings. The patient who has a serious disorder that is causing symptoms or a serious disordersthat is not causing the symptoms but is covered up by the pain disorder.
My favorite patients to treat are patients who have had MRI's, CAT scans, Brain Scans, numerous blood tests ruling out organic diseases. These patients are "safe" because all the severe problems have been eliminated as possible causes of the problem.
Neuromuscular Dentistry cannot treat temporal arteritis which is usually treated with steroid but often dissapears after a biopsy.
PUBMED Abstract
Ugeskr Laeger. 2009 Jan 12;171(3):125-6.
[Necrosis of the tongue triggered by ergotamine in unrecognized temporal arteritis]
[Article in Danish]
Olesen JB.
Regionshospitalet Horsens, Medicinsk Afdeling. Jesper.blegvad@ki.au.dk
Tongue necrosis is a rare complication in arteritis temporalis. Our case is a 74-year-old patient who presented with weight loss, tiredness and fever during a 2-3-month period after ingestion of 2 mg ergotamine to treat her migraine. Tongue necrosis then occurred after ingestion of another 2 mg of ergotamine. Our patient had no preexisting diagnosis of arteritis temporalis. We reviewed possible clinical manifestations of temporal arteritis and cases of tongue necrosis in the world literature. It is possible that ergotamine can cause necrosis due to vasoconstriction of blood vessels which have an unstable blood flow.
PMID: 19174020 [PubMed - indexed for MEDLINE]
Ergotamine is a well known drug in migraine treatment and this is an unusual case. With neuromuscular dentistry we are always on the look out for red herrings. The patient who has a serious disorder that is causing symptoms or a serious disordersthat is not causing the symptoms but is covered up by the pain disorder.
My favorite patients to treat are patients who have had MRI's, CAT scans, Brain Scans, numerous blood tests ruling out organic diseases. These patients are "safe" because all the severe problems have been eliminated as possible causes of the problem.
Neuromuscular Dentistry cannot treat temporal arteritis which is usually treated with steroid but often dissapears after a biopsy.
PUBMED Abstract
Ugeskr Laeger. 2009 Jan 12;171(3):125-6.
[Necrosis of the tongue triggered by ergotamine in unrecognized temporal arteritis]
[Article in Danish]
Olesen JB.
Regionshospitalet Horsens, Medicinsk Afdeling. Jesper.blegvad@ki.au.dk
Tongue necrosis is a rare complication in arteritis temporalis. Our case is a 74-year-old patient who presented with weight loss, tiredness and fever during a 2-3-month period after ingestion of 2 mg ergotamine to treat her migraine. Tongue necrosis then occurred after ingestion of another 2 mg of ergotamine. Our patient had no preexisting diagnosis of arteritis temporalis. We reviewed possible clinical manifestations of temporal arteritis and cases of tongue necrosis in the world literature. It is possible that ergotamine can cause necrosis due to vasoconstriction of blood vessels which have an unstable blood flow.
PMID: 19174020 [PubMed - indexed for MEDLINE]
Article in Journal of American Osteopathic Association on role of trigeminal nerve in migraines. Why Osteopathy, Chiropractic, A/O and NUCCA work.
Osteopathic manipulation and Chiropractic manipulation both treat headaches by changing input into the trigeminal nerve much like neuromuscular dentistry does. The article states: " Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache." The pathology in the neck is addressed to reduce pain (nociceptive) input into the trigeminal nucleus caudalis. The easiest and most direct method of reducing nociceptive input into the trigeminal nerve is a diagnostic orthotic followed by definitive long term treatment. The beauty of neuromuscular dentistry is that correcting the stomatognathic/ trigeminal system leads to auto correction of many neck problems.
The reason that NUCCA and A/O (atlas orthogonal) chiropractic is so effective when used in conjunction with a neuromuscular orthotic is that the chiropractic and/or osteopathic adjustments hold when the underlying masticatory pathology is adressed.
J Am Osteopath Assoc. 2007 Nov;107(10 Suppl 6):ES10-6.
Diagnosing and managing migraine headache.
Mueller LL.
University Headache Center, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, 42 E Laurel Rd, University Doctors Pavilion, Ste 1700, Stratford, NJ 08084-1354, USA. SOMPhysicians@umdnj.edu
Comment in:
J Am Osteopath Assoc. 2008 Apr;108(4):191; author reply 191, 214.
Headache is one of the chief complaints among patients visiting primary care physicians. Diagnosis begins with exclusion of secondary causes for headache. More than 90% of patients will have a primary-type headache, so diagnosis can often be completed without further testing. Although tension-type headaches are the most common kind of headache, patients with this type of headache rarely seek treatment unless occurrence is daily. Migraine, which affects more than 30 million people in the United States, is the most common headache diagnosis for which patients seek treatment. Migraine is a chronic, often inherited condition involving brain hypersensitivity and a lowered threshold for trigeminal-vascular activation. Intermittent debilitating attacks are characterized by autonomic, gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease in a patient's quality of life, as measured by physical, mental, and social health-related instruments. Accurate assessment of a patient's disability will guide physicians in prescribing appropriate modes of therapy. However, migraine remains underdiagnosed, and patients with migraine remain undertreated. A comprehensive treatment approach to migraine may include nonpharmacologic measures, as well as abortive and prophylactic medications. Informing patients about realistic treatment expectations, possible delayed efficacy of medications, and avoidance of caffeine and overuse of medications is critical for successful outcomes. Management of migraine is a dynamic process, because headaches evolve over time and medication tachyphylaxis may occur, necessitating changes in therapy. Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache.
PMID: 17986672 [PubMed - indexed for MEDLINE]
The reason that NUCCA and A/O (atlas orthogonal) chiropractic is so effective when used in conjunction with a neuromuscular orthotic is that the chiropractic and/or osteopathic adjustments hold when the underlying masticatory pathology is adressed.
J Am Osteopath Assoc. 2007 Nov;107(10 Suppl 6):ES10-6.
Diagnosing and managing migraine headache.
Mueller LL.
University Headache Center, University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine, 42 E Laurel Rd, University Doctors Pavilion, Ste 1700, Stratford, NJ 08084-1354, USA. SOMPhysicians@umdnj.edu
Comment in:
J Am Osteopath Assoc. 2008 Apr;108(4):191; author reply 191, 214.
Headache is one of the chief complaints among patients visiting primary care physicians. Diagnosis begins with exclusion of secondary causes for headache. More than 90% of patients will have a primary-type headache, so diagnosis can often be completed without further testing. Although tension-type headaches are the most common kind of headache, patients with this type of headache rarely seek treatment unless occurrence is daily. Migraine, which affects more than 30 million people in the United States, is the most common headache diagnosis for which patients seek treatment. Migraine is a chronic, often inherited condition involving brain hypersensitivity and a lowered threshold for trigeminal-vascular activation. Intermittent debilitating attacks are characterized by autonomic, gastrointestinal, and neurologic symptoms. Migraine results in a marked decrease in a patient's quality of life, as measured by physical, mental, and social health-related instruments. Accurate assessment of a patient's disability will guide physicians in prescribing appropriate modes of therapy. However, migraine remains underdiagnosed, and patients with migraine remain undertreated. A comprehensive treatment approach to migraine may include nonpharmacologic measures, as well as abortive and prophylactic medications. Informing patients about realistic treatment expectations, possible delayed efficacy of medications, and avoidance of caffeine and overuse of medications is critical for successful outcomes. Management of migraine is a dynamic process, because headaches evolve over time and medication tachyphylaxis may occur, necessitating changes in therapy. Pathologic findings in the neck constitute an accepted etiology or precipitant for headache. Osteopathic manipulative treatment may reduce pain input into the trigeminal nucleus caudalis, favorably altering neuromuscular-autonomic regulatory mechanisms to reduce discomfort from headache.
PMID: 17986672 [PubMed - indexed for MEDLINE]
NEUROMUSCULAR DENTISTRY FINDING A NEUROMUSCULAR DENTIST DIRECTORY TIRED OF HEADAXCHES? WE WILL HELP YOU LOCATE A NEUROMUSCULAR DENTIST
I have had an enormous respones from visitors to this website looking for a neuromuscular dentist and not finding one listed in their area. If you need help find a neuromuscular dentist we try our best to connect you with one.
I do ask for feedback on doctors because I do not know all of them personally. I am most happy when I can refer to an excellent clincian that I trust.
While I believe that neuromuscular dentistry is essential for a majority of patients it does not exclude many other varieties of treatment in conjunction with NMD.
Quality of Life is the name of the game. We want to help you on your journey to that better quality of life.
I do ask for feedback on doctors because I do not know all of them personally. I am most happy when I can refer to an excellent clincian that I trust.
While I believe that neuromuscular dentistry is essential for a majority of patients it does not exclude many other varieties of treatment in conjunction with NMD.
Quality of Life is the name of the game. We want to help you on your journey to that better quality of life.
Pain is worse after arthrocentesis.
Brenda comments : I HAVE HAD AN ANTERIOR DISC DISCPLACEMENT A YEAR AGO AND HAVE BEEN IN CONSTANT PAIN EVER SINCE. NOW BOTH SIDES HURT AND I AM VERY DISCOURAGED. HAD AN ARTHROCENTESIS THAT DID NOT WORK, I AM ACTUALLY WORSE. IS THERE ANY HOPE? I WEAR A BITE GUARD AT NIGHT AND SLEEP ON MY BACK. JUST STARTED TAKING LYRICA WHICH DOESN'T SEEM TO WORK. PLEASE PLEASE HELP ME. THIS HAS CONSUMED MY LIFE FOR THE PAST YEAR.
Dr Shapira Response:
Dear Brenda,
Yes there is hope, but there are no magic cures.
It is often thought that all the pain is from the joint but that is rarely the case. Many times we can eliminate the pain but reduced motion due to internal derangement continues. Does it only hurt when you move your jaw or is the pain continuous? You stated it was constant. Joint pain is almost always associated with jaw movement. Costant pain is usually from many different areas.
You mentioned you wore an appliance at night. If you have major instability wearing an appliance only a night is not sufficient. 24 hour wear of an neuromuscular orthotic is essential especially during the healing process. I never have patients undergo invasive procedures like arthrocentesis without a stabilizing neuromuscular orthotic. You did not say what caused the dislocation but usually patients are predisposed to dislocation due to their bite. I feel correcting the bite with a 24 hour orthotic should precede surgical intervention.
When I treat patients we work thru their pain, we initially shoot for a 50-80% pain reduction and that is usually relatively easy, We then try to relieve 50-80% of remaining pain. I like to describe my onion analogy. Treating pain is like peeling an onion, when you take away one layer you find a similar but different layer. Some layers may belong to the orthotic, some to trigger point injections etc. You work yourself thru the layers until you reach the hard white center, You without pain.
Unfortunately when you first dislocated the disk it wasn't immediately reduced. There are many techniques to reduce pain however it is impossible to determine what the best treatment is without a complete examination and history.
i would be happy to have you come for an evaluation. We have many patients who come from long distances (much farther) for treatment. You probably would have approximately a 2 1/2 hour drive to get here. Contact my office at 800-TM Joint for an appointment if you would like to have me evaluate the problem. In many cases we can give significant pain reduction at the consultation appointment. We are relatively close to the Milwaukee airport and very close to (private)Waukegan airport. We have a hotel at the country club that gives my patients discount rates.
If that is impossible I will try to find a neuromuscular dentist closer to you but many doctors do not have the experience and knowledge to treat more difficult cases. I can also work with a doctor in your area.
Dr Shapira Response:
Dear Brenda,
Yes there is hope, but there are no magic cures.
It is often thought that all the pain is from the joint but that is rarely the case. Many times we can eliminate the pain but reduced motion due to internal derangement continues. Does it only hurt when you move your jaw or is the pain continuous? You stated it was constant. Joint pain is almost always associated with jaw movement. Costant pain is usually from many different areas.
You mentioned you wore an appliance at night. If you have major instability wearing an appliance only a night is not sufficient. 24 hour wear of an neuromuscular orthotic is essential especially during the healing process. I never have patients undergo invasive procedures like arthrocentesis without a stabilizing neuromuscular orthotic. You did not say what caused the dislocation but usually patients are predisposed to dislocation due to their bite. I feel correcting the bite with a 24 hour orthotic should precede surgical intervention.
When I treat patients we work thru their pain, we initially shoot for a 50-80% pain reduction and that is usually relatively easy, We then try to relieve 50-80% of remaining pain. I like to describe my onion analogy. Treating pain is like peeling an onion, when you take away one layer you find a similar but different layer. Some layers may belong to the orthotic, some to trigger point injections etc. You work yourself thru the layers until you reach the hard white center, You without pain.
Unfortunately when you first dislocated the disk it wasn't immediately reduced. There are many techniques to reduce pain however it is impossible to determine what the best treatment is without a complete examination and history.
i would be happy to have you come for an evaluation. We have many patients who come from long distances (much farther) for treatment. You probably would have approximately a 2 1/2 hour drive to get here. Contact my office at 800-TM Joint for an appointment if you would like to have me evaluate the problem. In many cases we can give significant pain reduction at the consultation appointment. We are relatively close to the Milwaukee airport and very close to (private)Waukegan airport. We have a hotel at the country club that gives my patients discount rates.
If that is impossible I will try to find a neuromuscular dentist closer to you but many doctors do not have the experience and knowledge to treat more difficult cases. I can also work with a doctor in your area.
Neuromuscular dentistry at Delany Dental Care in Gurnee, Il
Check out my dental website for additional information on Neuromuscular Dentistry
http://www.delanydentalcare.com/neuromuscular.html
http://www.delanydentalcare.com/neuromuscular.html
Sunday, February 14, 2010
neuromuscualr dentistry and headache elimination
The following is a reprint of my article I was asked to write for the American Equilibation society. There are a couple of pictures that are not included in the text but can be found on the Sleep and Health Journal Site @ http://www.sleepandhealth.com/neuromuscular-dentistry
This article was written to explain Neuromuscular Dentistry to TMJ dentists who are not familiar with the field. I firmly believe that all TMJ treatment is better if neuromuscular dental techniques are used to perfect position.
I HAVE ALSO INCLUDED AFTER MY ARTICLE AN ABSTRACT OF AN ARTICLE BY BARRY COOPER DDS IN CRANIO WHERE HE FOUND "OVERWHELMING RELIEF" IN PATIENTS WITH NEUROMUSCULAR ORTHOTIC USE.
Dr Cooper has done an enormous service to all headache sufferers by his careful documentation of treatment. Insurance companies no longer have any justification for not covering neuromuscular dentistry in total. He is also a Past President of ICCMO and the founding Chairman of the Alliance of Temporomandibular disorders.
Neuromuscular Dentistry
NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)
Ira L Shapira DDS, DABDSM, DAAPM, FICCMO
Neuromuscular Dentistry remains an enigma to many dentists who do not understand the purposes of the electrodes, the TENS, the computers and more. It has unfairly become a target of poor and misleading definitions by doctors who do not understand its basic principles.
There are several basic premises that underlie Neuromuscular Dentistry. The first premise is that the stomatognathic muscles are the primary determinate of the mandibles position during all jaw functions (when the teeth are not in occlusion) and that rest position is one of the most important positions in dentistry. Rest position is a maxillary to mandibular jaw relation where the teeth are not in occlusion but are prepared to occlude. In Neuromuscular Dentistry Rest is a position of bilaterally equal and low muscle tonicity from which the mandible moves into full occlusion with minimal muscle accommodation. Following closure from rest position the mandible should return to rest with similarly balanced low muscle tonicity. Rest position is determined not only by the mandibles relation to the cranium but also by the position of the head relative to the body, the suprahyoid and infrahyoid muscles and the position of the hyoid bone. To fully understand the relation of jaw movement to head posture read the Quadrant Theorem of GUZAY (Available from the ADA Library). In essence it shows in engineering terms that after accounting for both rotation and translation of the mandible the actual axis of rotation of the mandible is at the odontoid process of the second vertebrae not at the mandible condylar head.
The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system's control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque during closure. This means that there are no noxious contacts received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow free entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.
Swallowing is a primary activity when the jaw is closed into full occlusion. In order to swallow it is necessary to fixate the mandible and this happens as the teeth occlude. During chewing, speaking and other jaw functions the teeth do not actually occlude in normal function but are separated (during chewing by a bolus of food). Typically swallowing occurs approximately 2000 times a day and is momentary accounting for 6-10 minutes maximum time in occlusion over the course of the day and acts as a neuromuscular reset switch for trigeminally innervated muscles. During a healthy swallow the teeth will move freely without interference into full occlusion with bilateral equal contact and bilateral equal muscle activity and then return to rest position with low muscle tonicity. A deviate swallow as evidenced by scalloping of the tongue is a sign of a possible TMJ disorder and is also 80% predictive of sleep apnea (80% predictive in Dental study- 70% predictive ENT study)
Neuromuscular occlusion (myocentric) occurs when centric occlusion (maximum non-torqued intercuspation of teeth) is coincidental with a balanced muscle closure where the muscles will return to their relaxed state following closure. Myocentric is the ideal position for swallowing.
The dentist utilizing neuromuscular techniques does not determine a specific position of the condyles in the fossa. The position of the disk and condyle are determined primarily by the teeth (bite or orthotic during occlusal correction therapy) in occlusion (myocentric) and the application of muscle activity. Neuromuscular dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a neuromuscular reset switch during closure. Neuromuscular dentistry rejects the notion that manipulation of the patient's jaw by the intervention of the clinician muscles are more important in determining the relation of the components of the TM Joint than the muscles of the patient. Centric relation is not used as a reference position for mounting casts on an articulator. Centric Relation is considered a border movement of the mandible and as reported in orthopedic literature joints are rarely used in their border positions.
The HIP plane (defined by hamular notches, incisive papilla and the occipital condyles) and/or Campers plane is used to relate the maxilla to an articulator. When cosmetic considerations are involved photos are used to to incorporate this physiologic plane to soft tissues of the face. Ideally the occlusal plane (parallel to the HIP Plane) will bisect the odontoid process of the axis of the atlantoaxial joint the actual center of rotation for the mandible after accounting for translation and rotation according to the quadrant theorem.
This occlusal plane will be at a 90-degree angle to gravitational force when the head is in an upright position. A neuromuscular bite is used to mount the
mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409
Neuromuscular dentistry considers many of the problems associated with TMD to be repetitive strain injuries. Movements become harmful when closure requires excessive accommodation and then the system fails at its weakest link. If the weakest link is muscle health we will see formation of tender sore muscles with eventual formation of taut bands and trigger points. If there is muscle overuse from clenching and/or grinding there will be post exercise pain secondary to anaerobic lactic acid build-up. If the weakest point is in the TM Joint then when repetitive strain occurs the muscle accommodation will lead to increased intra-articular pressure. This again will break down the joint at its weakest point. This may occur as a displaced disk or as wear of articular surfaces or many other conditions. It may come at the expense of the bone of the condyle leading to flattening or beaking of the condyle. Clenching and bruxism are two particularly well-known and harmful parafunctional habits that lead to varied repetitive strain injuries. There are many other parafunctions that can lead to problems. Some parafunctions are actually protective muscle accommodation such as the deviated or reversed swallow that protects the TM Joints and masticatory muscles at the expense of altered head, hyoid and spine position and consequent muscle problems.
The second type of problems would be described as I/O or Input/ output errors in computer lingo. The CNS is essentially a biological computer and is affected by input from afferent nerves from the body. Autonomic system function include the fight or flight response with concomitant release of adrenaline that alters the heart rate, blood pressure, muscle tone etc. This system effects the Hypothalamus pituitary complex with feedback to the adrenals and effects on ACTH and cortisol levels. During periods of acute stress these effects have a positive survival value but during chronic stress become a liability to the individual as described by Hans Selye in his book “The Stress of Life†and his discussion of the General Adaptation Syndrome. There are numerous biochemical changes that occur in the brain secondary to aberrant or nociceptive input into the brain these can be affected by correction of the neurological input, by using drugs to change the brain chemistry or a combination of these approaches. Ideally correction of the underlying cause of these biochemical changes is the preferred method of treatment.
The utilization of TENS or transcutaneous neural stimulation over the coronoid notch has been shown by Mitani and Fujii (1974 J. Dent Res.) to block the motor division of the trigeminal nerve and relax the musculature via anti-dromic impulses (hyperpolarisation) to both the alpha and gamma motor neurons without influence from proprioceptive and nocioceptive (tooth contacts) inputs The TENS is then use to create a balanced synchronize pulsing to find the trajectory of closure where a myocentric registration can be obtained. The muscles will return to their relaxed position following closure into myocentric.
The use of Computerized mandibular jaw tracking allows the dentist to measure and record resting jaw position relative to the cranium at a given head position. The location of myocentric occlusion is determined by the dentist with the aid of information from tracings recorded.
Electromyography or EMG is used to record relative values of resting muscle activity of masticatory muscles as well as muscles such as Sternocleidomastoid or Trapezius. While there are no absolute “normal values†of resting muscles the clinician uses his information to compare muscle activity within a given patient. Muscles should be approximately equal activity bilaterally. Thomas 1990 in Frontiers of Oral Physiology vol 7 pp162-170 demonstrated that Spectral analysis of the post TENS EMG may be utilized to evaluate muscle fatigue and differentiate between muscle atrophy or fatigue or relaxed muscle states. This was later confirmed by Frucht, Jonas and Kappert at Frieberg University in 1995 (Fortschr.Kieferorthop vol 56 pp 245-253)
Utilizing the two modalities together allows the clinician to evaluate the rest position of the jaw and simultaneously the health and functional activity of the muscles.
The EMG also allows tests to evaluate the functional capacity of the muscles and again compare the right and left sides for symmetry. The use of functional recordings (during clenching and closure into centric occlusion) allows the clinician to evaluate whether or not muscle function is satisfactory and functional. The use of EMG also allows evaluation and correction of first contact of closure position within microseconds bases on firing order of the masseter and temporalis muscles. The first point of contact on closure is vitally important and equilibration of orthotics and dentition must be finely adjusted until first contact is evenly dispersed on posterior dentition.
Neuromuscular dentistry is very concerned with the effects of mandibular position on the body as a whole and on the effects of the body on jaw and head position. The work of Sherrington and the righting reflex explains how ascending and descending disorders affect a patient. These phenomena have been best explained by Norman Thomas BDS, PhD. I will not attempt to explain this complicated topic in this agenda, which may be found in Anthology of ICCMO vol V pp159-170. It obviously must incorporate the Quadrant Theorem of Casey Guzay, the physiological aspects of the balance organ of the inner ear and the vestibular apparatus located in the brainstem as well as visual feedback. The control of sympathetic and parasympathetic systems by the cerebellum is quite intricate and also affected by head position.
Correction of the chewing cycle is an important part of occlusal finalization. It must be understood that the chewing cycle is different on the each side and that interferences can occur on both the opening and closing strokes of the chewing cycle. Interferences in chewing strokes are easiest to detect by study of the chewing strokes on computerized mandibular scans (MKG). Head position during chewing is not is normally in the upright head position but in the feeding position approximately a 30-degree anterior head flexion. Correction of the chewing cycle is at least as important as correction of right, left and protrusive excursions. Chewing is a healthy function of the craniomandibular apparatus where as excursive movements are actually exercises in parafunctional movements.
There is more commonality to treatment of TMJ disorders by neuromuscular and non-neuromuscular dentists than differences and complications caused by neural intensification in the reticular activating system, emotional aspects and the relation to the limbic system, connections to the sympathetic and parasympathetic nervous systems via the Sphenopalatine Ganglion and sympathetic chain, and chemical changes and cerebroplastic changes that occur during chronic pain leading to hyperalgesia and allodynia all can be discussed in greater detail and explained in relation to neuromuscular dentistry. The basics physiology including effects of Golgi tendon organs and muscle spindles on jaw muscles remain constant and must always be carefully considered during treatment.
Barney Jankelson's famous quote, "If it is measured it is a fact otherwise it is an opinion rings as true today as when he first said it. Neuromuscular dentistry is about making accurate measurements and the use of those measurements to improve the doctor's ability to make a differential diagnosis and tailor treatment to relieve pain and create stable restorative dentistry with healthy relaxed musculature.
I would like to make a disclaimer that this is my personal definition of Neuromuscular dentistry from 30 years of practice and to thank my mentors Barney Jankelson, Barry Cooper, Dayton Krajiec, Richard Coy, Harold Gelb, Peter Neff, Robert Jankelson and especially Jim Garry who first made me understand the connections between increased upper airway resistance and the common developmental aspects of sleep apnea and craniomandibular disorders. A special thank you for Dr Norman Thomas for his extraordinary help in understanding the complex physiology and anatomy underlying neuromuscular dentistry and in reviewing this paper prior to presentation.
My personal research in the 1980's as a visiting assistant professor at Rush Medical School examined the jaw relations of patients with obstructive sleep apnea based on neuromuscular evaluations of jaw relations with a Myotronic's kinesiograph and a myomonitor to find neuromuscular rest position. These studies showed jaw relations in the male apnea patients that were strikingly similar to those found in female TMD patients. The National Heart Lung and Blood Institute considers sleep apnea to be a TMJ disorder. The NHLBI published a report, “Cardiovascular and Sleep Related Consequences of TMJ Disorders†in 2001 that can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
Dr Shapira returned to Rush as an assistant professor at the sleep center in the 1990's where he treated a wide variety of obstructive apnea patients with commercial and customized intraoral sleep appliances. He was a founding and credentialed member of the Sleep Disorder Dental Society that has become the American Academy of Dental Sleep Medicine, He is a Diplomate of the American Board of Dental Sleep Medicine, on the board of the Illinois Sleep Society, a Diplomat of the American Academy of Pain Management, a Regent Fellow of the International College of Cranio-Manibular Orthopedics and a representative of that group to the TMD Alliance. He is a long time member of AES, AACFP, Academy of Sleep Medicine and the Chicago Dental Society. Dr Shapira teaches hands-on in-depth Dental Sleep Medicine courses to small groups at his Gurnee office. A family history of genetic cancer led Dr Shapira into research on stem cells an he also holds several patents (method and device) on the collection of stem cells during early minimally invasive removal of the uncalcified tooth bud of developing third molars. This procedure can be complete in minutes with greatly reduced morbidity compared to current surgical techniques used for removal of developed third molars. He hopes in the future that patients will routinely remove the tooth buds and collect and save the stem cells for anti-aging and regenerative medical uses.
PUBMED ABSTRACT FOLLOWS:
Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.
Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. tmjbcooper@aol.com
Comment in:
Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.
PMID: 18468270 [PubMed - indexed for MEDLINE]
This article was written to explain Neuromuscular Dentistry to TMJ dentists who are not familiar with the field. I firmly believe that all TMJ treatment is better if neuromuscular dental techniques are used to perfect position.
I HAVE ALSO INCLUDED AFTER MY ARTICLE AN ABSTRACT OF AN ARTICLE BY BARRY COOPER DDS IN CRANIO WHERE HE FOUND "OVERWHELMING RELIEF" IN PATIENTS WITH NEUROMUSCULAR ORTHOTIC USE.
Dr Cooper has done an enormous service to all headache sufferers by his careful documentation of treatment. Insurance companies no longer have any justification for not covering neuromuscular dentistry in total. He is also a Past President of ICCMO and the founding Chairman of the Alliance of Temporomandibular disorders.
Neuromuscular Dentistry
NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)
Ira L Shapira DDS, DABDSM, DAAPM, FICCMO
Neuromuscular Dentistry remains an enigma to many dentists who do not understand the purposes of the electrodes, the TENS, the computers and more. It has unfairly become a target of poor and misleading definitions by doctors who do not understand its basic principles.
There are several basic premises that underlie Neuromuscular Dentistry. The first premise is that the stomatognathic muscles are the primary determinate of the mandibles position during all jaw functions (when the teeth are not in occlusion) and that rest position is one of the most important positions in dentistry. Rest position is a maxillary to mandibular jaw relation where the teeth are not in occlusion but are prepared to occlude. In Neuromuscular Dentistry Rest is a position of bilaterally equal and low muscle tonicity from which the mandible moves into full occlusion with minimal muscle accommodation. Following closure from rest position the mandible should return to rest with similarly balanced low muscle tonicity. Rest position is determined not only by the mandibles relation to the cranium but also by the position of the head relative to the body, the suprahyoid and infrahyoid muscles and the position of the hyoid bone. To fully understand the relation of jaw movement to head posture read the Quadrant Theorem of GUZAY (Available from the ADA Library). In essence it shows in engineering terms that after accounting for both rotation and translation of the mandible the actual axis of rotation of the mandible is at the odontoid process of the second vertebrae not at the mandible condylar head.
The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system's control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque during closure. This means that there are no noxious contacts received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow free entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.
Swallowing is a primary activity when the jaw is closed into full occlusion. In order to swallow it is necessary to fixate the mandible and this happens as the teeth occlude. During chewing, speaking and other jaw functions the teeth do not actually occlude in normal function but are separated (during chewing by a bolus of food). Typically swallowing occurs approximately 2000 times a day and is momentary accounting for 6-10 minutes maximum time in occlusion over the course of the day and acts as a neuromuscular reset switch for trigeminally innervated muscles. During a healthy swallow the teeth will move freely without interference into full occlusion with bilateral equal contact and bilateral equal muscle activity and then return to rest position with low muscle tonicity. A deviate swallow as evidenced by scalloping of the tongue is a sign of a possible TMJ disorder and is also 80% predictive of sleep apnea (80% predictive in Dental study- 70% predictive ENT study)
Neuromuscular occlusion (myocentric) occurs when centric occlusion (maximum non-torqued intercuspation of teeth) is coincidental with a balanced muscle closure where the muscles will return to their relaxed state following closure. Myocentric is the ideal position for swallowing.
The dentist utilizing neuromuscular techniques does not determine a specific position of the condyles in the fossa. The position of the disk and condyle are determined primarily by the teeth (bite or orthotic during occlusal correction therapy) in occlusion (myocentric) and the application of muscle activity. Neuromuscular dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a neuromuscular reset switch during closure. Neuromuscular dentistry rejects the notion that manipulation of the patient's jaw by the intervention of the clinician muscles are more important in determining the relation of the components of the TM Joint than the muscles of the patient. Centric relation is not used as a reference position for mounting casts on an articulator. Centric Relation is considered a border movement of the mandible and as reported in orthopedic literature joints are rarely used in their border positions.
The HIP plane (defined by hamular notches, incisive papilla and the occipital condyles) and/or Campers plane is used to relate the maxilla to an articulator. When cosmetic considerations are involved photos are used to to incorporate this physiologic plane to soft tissues of the face. Ideally the occlusal plane (parallel to the HIP Plane) will bisect the odontoid process of the axis of the atlantoaxial joint the actual center of rotation for the mandible after accounting for translation and rotation according to the quadrant theorem.
This occlusal plane will be at a 90-degree angle to gravitational force when the head is in an upright position. A neuromuscular bite is used to mount the
mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409
Neuromuscular dentistry considers many of the problems associated with TMD to be repetitive strain injuries. Movements become harmful when closure requires excessive accommodation and then the system fails at its weakest link. If the weakest link is muscle health we will see formation of tender sore muscles with eventual formation of taut bands and trigger points. If there is muscle overuse from clenching and/or grinding there will be post exercise pain secondary to anaerobic lactic acid build-up. If the weakest point is in the TM Joint then when repetitive strain occurs the muscle accommodation will lead to increased intra-articular pressure. This again will break down the joint at its weakest point. This may occur as a displaced disk or as wear of articular surfaces or many other conditions. It may come at the expense of the bone of the condyle leading to flattening or beaking of the condyle. Clenching and bruxism are two particularly well-known and harmful parafunctional habits that lead to varied repetitive strain injuries. There are many other parafunctions that can lead to problems. Some parafunctions are actually protective muscle accommodation such as the deviated or reversed swallow that protects the TM Joints and masticatory muscles at the expense of altered head, hyoid and spine position and consequent muscle problems.
The second type of problems would be described as I/O or Input/ output errors in computer lingo. The CNS is essentially a biological computer and is affected by input from afferent nerves from the body. Autonomic system function include the fight or flight response with concomitant release of adrenaline that alters the heart rate, blood pressure, muscle tone etc. This system effects the Hypothalamus pituitary complex with feedback to the adrenals and effects on ACTH and cortisol levels. During periods of acute stress these effects have a positive survival value but during chronic stress become a liability to the individual as described by Hans Selye in his book “The Stress of Life†and his discussion of the General Adaptation Syndrome. There are numerous biochemical changes that occur in the brain secondary to aberrant or nociceptive input into the brain these can be affected by correction of the neurological input, by using drugs to change the brain chemistry or a combination of these approaches. Ideally correction of the underlying cause of these biochemical changes is the preferred method of treatment.
The utilization of TENS or transcutaneous neural stimulation over the coronoid notch has been shown by Mitani and Fujii (1974 J. Dent Res.) to block the motor division of the trigeminal nerve and relax the musculature via anti-dromic impulses (hyperpolarisation) to both the alpha and gamma motor neurons without influence from proprioceptive and nocioceptive (tooth contacts) inputs The TENS is then use to create a balanced synchronize pulsing to find the trajectory of closure where a myocentric registration can be obtained. The muscles will return to their relaxed position following closure into myocentric.
The use of Computerized mandibular jaw tracking allows the dentist to measure and record resting jaw position relative to the cranium at a given head position. The location of myocentric occlusion is determined by the dentist with the aid of information from tracings recorded.
Electromyography or EMG is used to record relative values of resting muscle activity of masticatory muscles as well as muscles such as Sternocleidomastoid or Trapezius. While there are no absolute “normal values†of resting muscles the clinician uses his information to compare muscle activity within a given patient. Muscles should be approximately equal activity bilaterally. Thomas 1990 in Frontiers of Oral Physiology vol 7 pp162-170 demonstrated that Spectral analysis of the post TENS EMG may be utilized to evaluate muscle fatigue and differentiate between muscle atrophy or fatigue or relaxed muscle states. This was later confirmed by Frucht, Jonas and Kappert at Frieberg University in 1995 (Fortschr.Kieferorthop vol 56 pp 245-253)
Utilizing the two modalities together allows the clinician to evaluate the rest position of the jaw and simultaneously the health and functional activity of the muscles.
The EMG also allows tests to evaluate the functional capacity of the muscles and again compare the right and left sides for symmetry. The use of functional recordings (during clenching and closure into centric occlusion) allows the clinician to evaluate whether or not muscle function is satisfactory and functional. The use of EMG also allows evaluation and correction of first contact of closure position within microseconds bases on firing order of the masseter and temporalis muscles. The first point of contact on closure is vitally important and equilibration of orthotics and dentition must be finely adjusted until first contact is evenly dispersed on posterior dentition.
Neuromuscular dentistry is very concerned with the effects of mandibular position on the body as a whole and on the effects of the body on jaw and head position. The work of Sherrington and the righting reflex explains how ascending and descending disorders affect a patient. These phenomena have been best explained by Norman Thomas BDS, PhD. I will not attempt to explain this complicated topic in this agenda, which may be found in Anthology of ICCMO vol V pp159-170. It obviously must incorporate the Quadrant Theorem of Casey Guzay, the physiological aspects of the balance organ of the inner ear and the vestibular apparatus located in the brainstem as well as visual feedback. The control of sympathetic and parasympathetic systems by the cerebellum is quite intricate and also affected by head position.
Correction of the chewing cycle is an important part of occlusal finalization. It must be understood that the chewing cycle is different on the each side and that interferences can occur on both the opening and closing strokes of the chewing cycle. Interferences in chewing strokes are easiest to detect by study of the chewing strokes on computerized mandibular scans (MKG). Head position during chewing is not is normally in the upright head position but in the feeding position approximately a 30-degree anterior head flexion. Correction of the chewing cycle is at least as important as correction of right, left and protrusive excursions. Chewing is a healthy function of the craniomandibular apparatus where as excursive movements are actually exercises in parafunctional movements.
There is more commonality to treatment of TMJ disorders by neuromuscular and non-neuromuscular dentists than differences and complications caused by neural intensification in the reticular activating system, emotional aspects and the relation to the limbic system, connections to the sympathetic and parasympathetic nervous systems via the Sphenopalatine Ganglion and sympathetic chain, and chemical changes and cerebroplastic changes that occur during chronic pain leading to hyperalgesia and allodynia all can be discussed in greater detail and explained in relation to neuromuscular dentistry. The basics physiology including effects of Golgi tendon organs and muscle spindles on jaw muscles remain constant and must always be carefully considered during treatment.
Barney Jankelson's famous quote, "If it is measured it is a fact otherwise it is an opinion rings as true today as when he first said it. Neuromuscular dentistry is about making accurate measurements and the use of those measurements to improve the doctor's ability to make a differential diagnosis and tailor treatment to relieve pain and create stable restorative dentistry with healthy relaxed musculature.
I would like to make a disclaimer that this is my personal definition of Neuromuscular dentistry from 30 years of practice and to thank my mentors Barney Jankelson, Barry Cooper, Dayton Krajiec, Richard Coy, Harold Gelb, Peter Neff, Robert Jankelson and especially Jim Garry who first made me understand the connections between increased upper airway resistance and the common developmental aspects of sleep apnea and craniomandibular disorders. A special thank you for Dr Norman Thomas for his extraordinary help in understanding the complex physiology and anatomy underlying neuromuscular dentistry and in reviewing this paper prior to presentation.
My personal research in the 1980's as a visiting assistant professor at Rush Medical School examined the jaw relations of patients with obstructive sleep apnea based on neuromuscular evaluations of jaw relations with a Myotronic's kinesiograph and a myomonitor to find neuromuscular rest position. These studies showed jaw relations in the male apnea patients that were strikingly similar to those found in female TMD patients. The National Heart Lung and Blood Institute considers sleep apnea to be a TMJ disorder. The NHLBI published a report, “Cardiovascular and Sleep Related Consequences of TMJ Disorders†in 2001 that can be found at http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf
Dr Shapira returned to Rush as an assistant professor at the sleep center in the 1990's where he treated a wide variety of obstructive apnea patients with commercial and customized intraoral sleep appliances. He was a founding and credentialed member of the Sleep Disorder Dental Society that has become the American Academy of Dental Sleep Medicine, He is a Diplomate of the American Board of Dental Sleep Medicine, on the board of the Illinois Sleep Society, a Diplomat of the American Academy of Pain Management, a Regent Fellow of the International College of Cranio-Manibular Orthopedics and a representative of that group to the TMD Alliance. He is a long time member of AES, AACFP, Academy of Sleep Medicine and the Chicago Dental Society. Dr Shapira teaches hands-on in-depth Dental Sleep Medicine courses to small groups at his Gurnee office. A family history of genetic cancer led Dr Shapira into research on stem cells an he also holds several patents (method and device) on the collection of stem cells during early minimally invasive removal of the uncalcified tooth bud of developing third molars. This procedure can be complete in minutes with greatly reduced morbidity compared to current surgical techniques used for removal of developed third molars. He hopes in the future that patients will routinely remove the tooth buds and collect and save the stem cells for anti-aging and regenerative medical uses.
PUBMED ABSTRACT FOLLOWS:
Cranio. 2008 Apr;26(2):104-17.
Establishment of a temporomandibular physiological state with neuromuscular orthosis treatment affects reduction of TMD symptoms in 313 patients.
Cooper BC, Kleinberg I.
Department of Oral Biology and Pathology, State University of New York (SUNY) Stony Brook School of Dental Medicine, USA. tmjbcooper@aol.com
Comment in:
Cranio. 2008 Jul;26(3):166; author reply 167.
The objective of this investigation was to test the hypothesis that alteration of the occlusions of patients suffering from temporomandibular disorders (TMD) to one that is neuromuscularly, rather than anatomically based, would result in reduction or resolution of symptoms that characterize the TMD condition. This hypothesis was proven correct in the present study, where 313 patients with TMD symptoms were examined for neuromuscular dysfunction, using several electronic instruments before and after treatment intervention. Such instrumentation enabled electromyographic (EMG) measurement of the activities of the masticatory muscles during rest and in function, tracking and assessment of various movements of the mandible, and listening for noises made by the TMJ during movement of the mandible. Ultra low frequency and low amplitude, transcutaneous electrical neural stimulation (TENS) of the mandibular division of the trigeminal nerve (V) was used to relax the masticatory muscles and to facilitate location of a physiological rest position for the mandible. TENS also made it possible to select positions of the mandible that were most relaxed above and anterior to the rest position when the mandible was moved in an arc that began at rest position. Once identified, the neuromuscular occlusal position was recorded in the form of a bite registration, which was subsequently used to fabricate a removable mandibular orthotic appliance that could be worn continuously by the patient. Such a device facilitated retention and stabilization of the mandible in its new-found physiological position, which was confirmed by follow up testing. Three months of full-time appliance usage showed that the new therapeutic positions achieved remained intact and were associated with improved resting and functioning activities of the masticatory muscles. Patients reported overwhelming symptom relief, including reduction of headaches and other pain symptoms. Experts consider relief of symptoms as the gold standard for assessment of effectiveness of TMD treatment. It is evident that this outcome has been achieved in this study and that taking patients from a less to a more physiological state is an effective means for reducing or eliminating TMD symptoms, especially those related to pain, most notably, headaches.
PMID: 18468270 [PubMed - indexed for MEDLINE]
Temporal Tendinitis: A Migraine Mimic Temporal Tendinitis is a very common disorder frequently misdiagnosed and/or mistaken for migraine.
There was an excellent article in Practical Pain Management by Edwin A Ernst III DMD on Temporal Tendinitis. Common pain reference sites (according to the article) for this condition include: Painful TM Joints (Temporomandibular joint or TMJ), Ear Pain and/or stuffiness in the ear, retro-orbital pain sometimes radiating to occiput and /or shoulder, upper and lower aching teeth, pain in or around the eye, pain in the lateral temple area, and occasionally pain in the area of the stylomandibular ligament. These pains are frequently accompanied by prodromal symptoms similar to migraine of Nausea, vomiting, photophobia and visual disturbances.
This can be extremely intense pain and is frequently initiated by trauma such as an auto accident. Many patients with this disorder can have trouble fitting their back teeth together. The pain can be unilateral or bilateral and patients will frequently use analgesics, opiods or visit hospital ER's because of the pain severity. Physicians rarely palpate the coronoid tendon therefore these patients are easily misdiagnosed. Intra-oral palpation is essential in the diagnostic process and most physicians are not trained in palpation of these important structures. Dr Ernst coined the phrase "The Migraine Mimic " in 1983 but many physicians are not familiar with craniofacial pain literature.
The actual problem is a tendenosis of the temporal tendon at the tip of the coronoid process. Increasing the pressure of palpation causes increases in the level of the pain. If a Migraine Mimic headache is evoked use of lidocaine diagnostic injection should lessen or alleviete the pain.
Treatment with local anesthetic and Sarapin and/or Steroid is recommended by Dr Ernst and if this is not curative he recommends radio-frequency thermoneurolysis. I have never found this to be necessary and prefer to try prolotherapy as a first line treatment and if that is not effective then utilize a steroid. If the pain is exquisitely acute than beginning with steroid may be advantageous.
Temporal tendinitis can also be found in chronic muscle disorder from chronic pathology but is usually significantly less intense. Patients can suffer for years with this condition and be treated for migraines with poor results and no long term resolution.
I still recommend correction of the neuromuscular position of the mandible with a diagnostic orthotic even when temporla tendinitis is diagnosed. If total relief is achieved a reevaluation of baseline jaw position is recommended before phase 2 therapy.
This can be extremely intense pain and is frequently initiated by trauma such as an auto accident. Many patients with this disorder can have trouble fitting their back teeth together. The pain can be unilateral or bilateral and patients will frequently use analgesics, opiods or visit hospital ER's because of the pain severity. Physicians rarely palpate the coronoid tendon therefore these patients are easily misdiagnosed. Intra-oral palpation is essential in the diagnostic process and most physicians are not trained in palpation of these important structures. Dr Ernst coined the phrase "The Migraine Mimic " in 1983 but many physicians are not familiar with craniofacial pain literature.
The actual problem is a tendenosis of the temporal tendon at the tip of the coronoid process. Increasing the pressure of palpation causes increases in the level of the pain. If a Migraine Mimic headache is evoked use of lidocaine diagnostic injection should lessen or alleviete the pain.
Treatment with local anesthetic and Sarapin and/or Steroid is recommended by Dr Ernst and if this is not curative he recommends radio-frequency thermoneurolysis. I have never found this to be necessary and prefer to try prolotherapy as a first line treatment and if that is not effective then utilize a steroid. If the pain is exquisitely acute than beginning with steroid may be advantageous.
Temporal tendinitis can also be found in chronic muscle disorder from chronic pathology but is usually significantly less intense. Patients can suffer for years with this condition and be treated for migraines with poor results and no long term resolution.
I still recommend correction of the neuromuscular position of the mandible with a diagnostic orthotic even when temporla tendinitis is diagnosed. If total relief is achieved a reevaluation of baseline jaw position is recommended before phase 2 therapy.
Friday, February 12, 2010
Sphenopalatine Ganglion Blocks are an easy for patients to use to prevent migraine and relieve tension-type headaches
The Sphenopalatine ganglion block can be used to prevent and/or relieve headaches and Migraines. I have used it for many years in my office as an adjunct for treating headaches and migraines in patients. While it is not effective for all patients there is a subgroup that remarkable relief from pain and a second group that can stop a migraine before it becomes full blown.
The real beauty of SPG blocks is that they are simple and safe and I teach patients how to use them at home when they need them. The block is done with a Q-tip with lidocaine. The q-tip is gently place in the nostril until the lidocaine soaked cotton tip is adjacent to the SPG. This is left in place for 20-30 minutes. It ia also effective for some patients with cluster headaches and sinus headaches. The results for some patients are miraculous while other patients have minimal change in symptoms. Some patients who do not get relief from the SPG block can prevent migraines and chronic daily headache by regular use a a preventitve agent.
This uses only lidocaine and is extremely minimal to no risk if there is not a lidocaine allergy.
This is not replacement for treating the underlying causes of the pain with a neuromuscular orthotic but is a great adjunct durng treatment and for those patients who do not get complete relief.
The real beauty of SPG blocks is that they are simple and safe and I teach patients how to use them at home when they need them. The block is done with a Q-tip with lidocaine. The q-tip is gently place in the nostril until the lidocaine soaked cotton tip is adjacent to the SPG. This is left in place for 20-30 minutes. It ia also effective for some patients with cluster headaches and sinus headaches. The results for some patients are miraculous while other patients have minimal change in symptoms. Some patients who do not get relief from the SPG block can prevent migraines and chronic daily headache by regular use a a preventitve agent.
This uses only lidocaine and is extremely minimal to no risk if there is not a lidocaine allergy.
This is not replacement for treating the underlying causes of the pain with a neuromuscular orthotic but is a great adjunct durng treatment and for those patients who do not get complete relief.
Monday, February 8, 2010
Sleep Apnea Appliances Can Help Resolve TMJ Clicking and Improve Headache Symptoms
Patients with morning headaches usually have either TMJ disorders or Sleep Apnea. Sleep Apnea can be treated with CPAP or an Oral Appliance. Patients who have TM Joint clicking and are undergoing treatment for headaches or TMD can benefit in several ways from having a night-time apnea appliance and a daytime neuromuscular orthotic.
A problem that is sometimes encountered with oral appliances for sleep apnea are undesired bite changes. These changes can actually be helpful when treating TMJ clicking and popping and headaches. The bite changes that occur are actuallly the healing of the TM Joint. The jaw usually postures forward unloadding the retrodiscal lamina of the TM Joint that is compressed in patients with clicking. The retrodiscal lamina rehydrates and does not let the condyle go into retrusive pathology which serves to stabilize the disk.
The Daytime appliance allows this position to stabilize and heal. In patients who are not undergoing treatment exercises are done to prevent this healing from occuring. The joints will frequently heal if placed in a healthy position. A recent paper showed no damage to the joints with sleep appliances.
The American Academy of Sleep Medicine recommends that dentists fitting patients with oral appliances for sleep apnea be well versed in treating TMJ disorders. There are many good reasons for this recomendation. Dentists who do not uderstand how bite changes affect the joints and the muscles as well as head posture can create difficult problems they do not have the expertise to treat. Please check my I HATE CPAP website (http://www.ihatecpap.com) for more information about the dangers of sleep apnea and on how oral appliances are used in treating sleep apnea.
A problem that is sometimes encountered with oral appliances for sleep apnea are undesired bite changes. These changes can actually be helpful when treating TMJ clicking and popping and headaches. The bite changes that occur are actuallly the healing of the TM Joint. The jaw usually postures forward unloadding the retrodiscal lamina of the TM Joint that is compressed in patients with clicking. The retrodiscal lamina rehydrates and does not let the condyle go into retrusive pathology which serves to stabilize the disk.
The Daytime appliance allows this position to stabilize and heal. In patients who are not undergoing treatment exercises are done to prevent this healing from occuring. The joints will frequently heal if placed in a healthy position. A recent paper showed no damage to the joints with sleep appliances.
The American Academy of Sleep Medicine recommends that dentists fitting patients with oral appliances for sleep apnea be well versed in treating TMJ disorders. There are many good reasons for this recomendation. Dentists who do not uderstand how bite changes affect the joints and the muscles as well as head posture can create difficult problems they do not have the expertise to treat. Please check my I HATE CPAP website (http://www.ihatecpap.com) for more information about the dangers of sleep apnea and on how oral appliances are used in treating sleep apnea.
Glasses and Headache Treatment: How your Optician can help relieve your Occipital and Neck Pain
An Optician can be a vital team member when it comes to treating headache pain. An Optometrist is a specialist in prescribing contanct lenses and glasses which can frequently help headaches coming from eye strain. An Opthamologist is a MD who specializes in diseases of the eyes and will do surgical interventions when necessary. Opthamologists can prescribe medications and prescribe contacts and glasses.
The Optician is offered considered someone who sells glasses but can often be the most important member of the team when treating occiptital (back of head) headaches and neck pain. Patientw will frequently cause neck pain by poor posture when working in various conditions. A sharp Optometrist can angle the lenses on glasses in order to correct postual problems. An example would be tipping the lenses on an angle so the head must be upright to read from a desk thus preventing patients tipping their necks excessively causing cervical muscle spasm and occipital pain. The same holds true when using a computer of other tasks that glasses can effect head position.
In the textbook Myofascial Pain and Dysfunction: A Trigger Point Manual by Travell and Simons there is are excellent examples of how head posture can be affected by activities and how specially fitted glasses can correct these problems. My family I have used Brian Scott of Doyle opticians in Deerfield for many years and I refer patients to him frequently.
The informed optician can frequently make a enormous difference in patients neck pain.
The Optician is offered considered someone who sells glasses but can often be the most important member of the team when treating occiptital (back of head) headaches and neck pain. Patientw will frequently cause neck pain by poor posture when working in various conditions. A sharp Optometrist can angle the lenses on glasses in order to correct postual problems. An example would be tipping the lenses on an angle so the head must be upright to read from a desk thus preventing patients tipping their necks excessively causing cervical muscle spasm and occipital pain. The same holds true when using a computer of other tasks that glasses can effect head position.
In the textbook Myofascial Pain and Dysfunction: A Trigger Point Manual by Travell and Simons there is are excellent examples of how head posture can be affected by activities and how specially fitted glasses can correct these problems. My family I have used Brian Scott of Doyle opticians in Deerfield for many years and I refer patients to him frequently.
The informed optician can frequently make a enormous difference in patients neck pain.
Chicaqgo: Headache Treatment and Neuromuscular Dentistry
I have received several e-mails from patients who tell me that there are no dentists listed in their area. We will help you find a Neuromuscular Dentist in your area. I practice in Gurnee, Illinois and see patients primarily from Northern Illinois and Southern Wisconsin. I can do some procedures and initial consults on TMJ disorders at the offices of Chicagoland Dental Sleep Medicine Associates in Skokie and Schaumburg but patients with difficult headaches usually need to come to Gurnee. My office is especially convenient for North Shore suburbs of Chicago as well as Northwest suburbs.
I teach a course in Dental Sleep Medicine to dentists from around the U.S. and my team can arrange for out of own patients who want to travel to Chicago for Neuromuscular Dental Treatment.
Neuromuscular Dentistry for Treatment of headaches involves at least two extended appointments at the start of treatment. Ideally out of town patients will spend three days to begin treatment. The first visit for local patients is usually a consultation we can start treatment for long distance patience if previous arrangements are made.
Following the consultation appointment, treatment begins at the first appointment with a comprehensive examination and neuromuscular work up. The diagnostic orthotic is deliverd at the second visit visit. Long distance patients actually have a full day of treatment (the equivlant of two appointments) with the appliance being delivered on the first day. The patient will be seen early the next day for correcting the diagnostic orthotic to rflect changes in posture as muscles continual to release and normalize. A second visit in the afternoon will often include nerve blocks or trigger points if there is still residual pain. Some patients will leave after the second day but I prefer to have their next appointment the morning of the third day before they go home. We will usually schedule the next vist for 2 weeks later but if pain is completely relieved we may postpone the next appointment.
All patients are different and bring unique challenges and treatment is adjusted to individual patients. Many patients bring their spouse to the first series of appointments though this is not necessary.
Diagnostic orthotics are used in phase I treatment. The diagnostic orthotic is meant for a few months of use decrese pain and stbilize posture. If the patient decides they are substantially improved we recommend a second phase of treatment for long term stabilization. Long term stanilization and permanent changes are usually avoided at the initial series of visits.
Long term stabilization can take many different forms but it is designed to maintain the relief afforded by the diagnostic orthotic.
I teach a course in Dental Sleep Medicine to dentists from around the U.S. and my team can arrange for out of own patients who want to travel to Chicago for Neuromuscular Dental Treatment.
Neuromuscular Dentistry for Treatment of headaches involves at least two extended appointments at the start of treatment. Ideally out of town patients will spend three days to begin treatment. The first visit for local patients is usually a consultation we can start treatment for long distance patience if previous arrangements are made.
Following the consultation appointment, treatment begins at the first appointment with a comprehensive examination and neuromuscular work up. The diagnostic orthotic is deliverd at the second visit visit. Long distance patients actually have a full day of treatment (the equivlant of two appointments) with the appliance being delivered on the first day. The patient will be seen early the next day for correcting the diagnostic orthotic to rflect changes in posture as muscles continual to release and normalize. A second visit in the afternoon will often include nerve blocks or trigger points if there is still residual pain. Some patients will leave after the second day but I prefer to have their next appointment the morning of the third day before they go home. We will usually schedule the next vist for 2 weeks later but if pain is completely relieved we may postpone the next appointment.
All patients are different and bring unique challenges and treatment is adjusted to individual patients. Many patients bring their spouse to the first series of appointments though this is not necessary.
Diagnostic orthotics are used in phase I treatment. The diagnostic orthotic is meant for a few months of use decrese pain and stbilize posture. If the patient decides they are substantially improved we recommend a second phase of treatment for long term stabilization. Long term stanilization and permanent changes are usually avoided at the initial series of visits.
Long term stabilization can take many different forms but it is designed to maintain the relief afforded by the diagnostic orthotic.
Sunday, February 7, 2010
Neuromuscular Dentistry (NMD) and the PPM Mouthguard help the New Orleans Saints win the Superbowl: Headache Treatment is where NMD really shines.
The same Neuromuscular Dentistry that was used to create Pure Power Mouthguards(PPM) to help the New Orleans Saints is what is put into neuromuscular orthotics to treat chronic pain, migraines and tension type headaches. There is a continuous spectrum from total health and ideal function to poor health and function. The PPM mouthguard is trying to improve highly functional athletes with neuromuscular dentistry. Cosmetic dentistry utilizes neuromuscular dentistry to determine ideal jaw position and fuction for ideal cosmetics.
Headache treatment with neuromuscular dentistry is taking patients with pathological input that causes changes to the central nervous system and reducing the nociceptive input. As the pathology is removed the system heals. In medicine the best a doctor can hope for is to remove the impediments to healing so the body can heal itself. This is found in every field of medicine in every culture. We want to allow healing.
The brain acts as a computer noxious stimuli provoke nociceptive input. The expression Garbage in - Garbage out can apply to our brains as well as computers. The trigeminal nerve (Dentist's Nerve) is the largest contributor of input into the brain. This input comes in from jaw muscles, jaw joints, teeth and periodontal membranes. The trigeminal nerve also goes to the ling of the sinuses, tensor of the ear drum (tensor veli tympani), the tensor of the eustacian tube (tensor veli palatini) and controls blood flow to the anterior 2/3 of the brain thru the meninges.
Input into the brain is not a simple single step (like a light switch) but rather a complex menageries of thousands and thousands of switches. Different combinations of these switches can cause different effects. They can change the neurotransmitters in the brain like Serotonin or norepinephrine. These are the same neurotransmitters affected by powerful drugs used to treat pain and depression. Neuromuscular Dentistry strives to bring a healthy homeostasis into this input to allow healing. Central sensitization results when excessive long term nociceptive input wreaks havoc causing conditions like allodynia and hyperalgesia or CRPS (complex Regional Pain Syndromes or RSD, reflex sympathetic dystrophy syndrome) The body basically becomes overly sensitive to catecholamines or other neurotransmitters. This is usually the result of an I/O or input output error of the nervous system. Neuromuscular Dentistry corrects pathological input allowing healing and correction of output.
Headache treatment with neuromuscular dentistry is taking patients with pathological input that causes changes to the central nervous system and reducing the nociceptive input. As the pathology is removed the system heals. In medicine the best a doctor can hope for is to remove the impediments to healing so the body can heal itself. This is found in every field of medicine in every culture. We want to allow healing.
The brain acts as a computer noxious stimuli provoke nociceptive input. The expression Garbage in - Garbage out can apply to our brains as well as computers. The trigeminal nerve (Dentist's Nerve) is the largest contributor of input into the brain. This input comes in from jaw muscles, jaw joints, teeth and periodontal membranes. The trigeminal nerve also goes to the ling of the sinuses, tensor of the ear drum (tensor veli tympani), the tensor of the eustacian tube (tensor veli palatini) and controls blood flow to the anterior 2/3 of the brain thru the meninges.
Input into the brain is not a simple single step (like a light switch) but rather a complex menageries of thousands and thousands of switches. Different combinations of these switches can cause different effects. They can change the neurotransmitters in the brain like Serotonin or norepinephrine. These are the same neurotransmitters affected by powerful drugs used to treat pain and depression. Neuromuscular Dentistry strives to bring a healthy homeostasis into this input to allow healing. Central sensitization results when excessive long term nociceptive input wreaks havoc causing conditions like allodynia and hyperalgesia or CRPS (complex Regional Pain Syndromes or RSD, reflex sympathetic dystrophy syndrome) The body basically becomes overly sensitive to catecholamines or other neurotransmitters. This is usually the result of an I/O or input output error of the nervous system. Neuromuscular Dentistry corrects pathological input allowing healing and correction of output.
Saturday, February 6, 2010
Trigger point injections and Greater Occipital Nerve block treating transofrmed migraine. The Role of Neuromuscular Dentistry in Long Term Relief
Transformed Migraine (common Migraine) usually has a history of beginning as episodic migraine attacks which increse in frequency. This occurs over aperiod of months to years and the Transformed Migraine (TM) occur frequently, often daily and are a combination of vascular and Tension-type Headaches. The TM can very from mild to moderate severity with epsodes of increased severity. These headaches usually begin in teen years or early 20's. Transformed Migraine attacks are frequently accompanied by nauseau, phonophobia (sensitivity to noise), photophobia (sensitivity to light) which lessen over time. A large porportion of patients are women with 90% of whom have a history of migraine without aura.
Patients with Transformed Migraines frequently report a vascular quality, that exhibits a throbbing nature. In some cases, it can be difficult to distinguish between tension-type headaches and TM. These headaches are also identical to headaches frequently seen in patients with TMD or temporomandibular dysfunction. The history of headaches beginning in teen years and usually women fit the profile of TMD sufferers. There is a theory that all headaches are a combination of neurovascular and muscular headache pain. In this view of headaches the muscular or tension-type headache can trigger the vascular (or neurogenic) headache and the Vascular (or neurogenic ) headache can serve trigger the muscular headache. This theory always fits headaches arising from the trigeminal nervous system because it controls meningeal blood flow and masticatory muscles.
These headaches usually respon beautifully to treatment with a neuromuscular orthotic which can frequently eliminate the majority of pain. Some patients, especially those with long standing pain have developed myofascial trigger points that are not completely relieved by TENS and an orthotic. Those patients frequently can be helped by manual trigger point therapy, trigger point injections and/or nerve blocks to break up myofascial trigger points.
Unfortunately clinical studies have shown that almost 80% of these patients overuse symptomatic medications. This medication over-use can frequently increase migraine occurrence. The development of Medication Overuse Headache (MOH), also known as Rebound Headache is often seen with daily use of analgesics, either prescription or over-the-counter. Other risk factors for TM or CM include high life stress (as seen in TMJ or TMD patients), snoring and /or sleep apnea a TMJ disorder according to the NHLBI (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf), head injury and history of orofacial trauma including wisdom teeth extraction and/or orthodontics (especially involving 4 bicuspid extraction).
Depression and anxiety are features shared by patients with Migraine, TMJ disorders, Tension-type headaches and Chronic Daily Headaches. Healthy lifestyle habits including sleeping, eating and exercising are important for all of these disorders. The typical neurologist will prescribe a variety of preventive therapies including Antidepressant and Anticonvulsant medications for transformed Migraine with a goal of reverting the headaches back from daily to episodic attacks. The Neuromuscular Dentist approach is to eliminate the myofascial pain by use of TENS and a neuromuscular orthotic and eventually eliminate the nociceptive input to the brain to eliminate the original migraineor vascular headache. The original migraine is usually a result of unhealthy neuromuscular input from the trigeminal nerve or airway collapse at night due to uderlying jaw pathology that leads to snoring, sleep apnea and upper airway resistance syndrome (sleep distrubance known to cause/promote fibromyalgia)
The use of triggr point infections is a way to hasten recovery when utilizing neuromuscular dentistry. An article in The Journal of Neurology, Neurosurgery and Psychiatry examined the effect of greater occipital nerve blocks and trigger point injections on Transformed Migraine (pubmed abstract below). The article compared these proceedures with and without use of triamcinolone which the authors concluded was unnecessary for the therapeutic effect. The therapeutic effect was impressive, there was immediate reduction in pain (3.2 points) and neck pain was reduced(1.5 points) and resulted in 2.7/3.8 headache free days. Th results were equal with or without the steroid. The use of anaesthetic injections to turn off migraine pain is effective for a short period of time but when combined with neuromuscular dentistry and the use of TENS and an orthotic to prevent recurrence of the problem can be part of a long term correction of this difficult problem.
Another article in Cranio (pubmed abstract below) "Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches." compared treatment of myofascial trigger points with three different methods.They found that " Statistically, all the groups showed favorable results for the evaluated requisites" "Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory." The treatment of myofascial trigger points successly treated the headaches. Breaking up the trigger points with the injection or the needle is effecteive without botulinum toxin or steroid use. Use of manual medicine, myotherapy and /or massage will also brek-up trigger points. Regardless of the method of eliminating the trigger points long term relief will depend on eliminating the noxious input to the trigeminal nervous system for long term relief. The use of the diagnostic neuromuscular dentistry orthotic is essential for most patients wanting to avoid a lifetime of drug use to treat the condition.
Yet another study in Headache (pubmed abstract below) "Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study." found very significant relief of headache pain of ETTH, Episodic Tension-Type Headaches by treatment of Cervical Myofacial Trigger Points. The study showed that trigger point injection with saline gave good results for up to 12 weeks where the Botox results did last for longer periods. Again this is a case calling for combination therapy of a Neuromuscular dentistry diagnostic orthotic and trigger point injections. Utilizing the combination should cause long term elimination of myofascial trigger points. Many patients will nor require the trigger point injections but they are helpful for difficult cases and to decrease treatment time with the diagnostic orthotic.
A diagnostic orthotic is used in Neuromuscular Dentistry (http://www.sleepandhealth.com/neuromuscular-dentistry) to eliminate pain and symptoms prior tolong term correction. This 2 phase treatment protocol allows patient neuromuscular stabilization and pain relief before making any irreverible occlusal changes.
One additional PubMed article is included below "The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine." which evaluated the effect of Greater Occipital Nerve Block on Migraine and
allodynia. Allodynia is when a stimulus that is not normally perceived as painful causes pain. The study had 19 patients and 17 or almost 90% had headache relief. All 19 patients had relief of allodynia. Neuromuscular Dentists should learn to use trigger point injections and Greater Occipital Nerve Blocks as part of comprehensive phase 1 treatment with neuromuscular orthotics to increase pain relief. Long term relief without the chronic use of drugs is ideally and frequently attainable with Neuromuscular Dentistry.
The Las Vegas Institute now teaches stimulation of the Accesory Nerve (cranial nerve XI) along with the Trigeminal Nerve (cranial nerve V) when utilizing TENS to relax muscles i
J Neurol Neurosurg Psychiatry. 2008 Apr;79(4):415-7. Epub 2007 Aug 6.
Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study.
Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD.
Department of Neurology, Thomas Jefferson University, 111 South 11th Street, Suite 8130, Philadelphia, PA 19107, USA. avi.ashkenazi@jefferson.edu
OBJECTIVE: To determine whether adding triamcinolone to local anaesthetics increased the efficacy of greater occipital nerve block (GONB) and trigger-point injections (TPIs) for transformed migraine (TM). METHODS: Patients with TM were randomised to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% + either saline or triamcinolone 40 mg. We assessed the severity of headache and associated symptoms before and 20 minutes after injection. Patients documented headache and severity of associated symptoms for 4 weeks after injections. Changes in symptom severity were compared between the two groups. RESULTS: Thirty-seven patients were included. Twenty minutes after injection, mean headache severity decreased by 3.2 points in group A (p<0.01) and by 3.1 points in group B (p<0.01). Mean neck pain severity decreased by 1.5 points in group A (p<0.01) and by 1.7 points in group B (p<0.01). Mean duration of being headache-free was 2.7+/-3.8 days in group A and 1.0+/-1.1 days in group B (p = 0.67). None of the outcome measures differed significantly between the two groups. Both treatments were well tolerated. CONCLUSIONS: Adding triamcinolone to local anaesthetics when performing GONB and TPIs was not associated with improved outcome in this sample of patients with TM.
PMID: 17682008 [PubMed - indexed for MEDLINE]
Cranio. 2009 Jan;27(1):46-53.
Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches.
Venancio Rde A, Alencar FG Jr, Zamperini C.
Marquette University School of Dentistry TMD and Orofacial Pain, P.O. Box 1881 Milwaukee, WI 53201-1881, USA.
Trigger point injections with different solutions have been studied mainly with regard to the management of myofascial pain (MFP) patient management. However, few studies have analyzed their effect in a chronic headache population with associated MFP. The purpose of this study was to assess if trigger point injections using botulinum toxin, lidocaine, and dry-needling injections for the management of local pain and associated headache management. Forty-five (45) myofascial pain patients with headaches that could be reproduced by activating at least one trigger point, were randomly assigned into one of the three groups: G1, dry-needling, G2, 0.25% lidocaine, at 0.25% and G3 botulinum toxin and were assessed during a 12 week period. Levels of pain intensity, frequency and duration, local postinjection sensitivity, obtainment time and duration of relief, and the use of rescue medication were evaluated. Statistically, all the groups showed favorable results for the evaluated requisites (p < or = 0.05), except for the use of rescue medication and local post injection sensitivity (G3 showed better results). Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory.
PMID: 19241799 [PubMed - indexed for MEDLINE]
Headache. 2009 May;49(5):732-43. Epub 2008 Oct 24.
Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study.
Harden RN, Cottrill J, Gagnon CM, Smitherman TA, Weinland SR, Tann B, Joseph P, Lee TS, Houle TT.
Center for Pain Studies, Rehabilitation Institute of Chicago, 446 E. Ontario, Chicago, IL 60611, USA.
OBJECTIVE: To evaluate the efficacy of botulinum toxin A (BT-A) as a prophylactic treatment for chronic tension-type headache (CTTH) with myofascial trigger points (MTPs) producing referred head pain. BACKGROUND: Although BT-A has received mixed support for the treatment of TTH, deliberate injection directly into the cervical MTPs very often found in this population has not been formally evaluated. METHODS: Patients with CTTH and specific MTPs producing referred head pain were assigned randomly to receive intramuscular injections of BT-A or isotonic saline (placebo) in a double-blind design. Daily headache diaries, pill counts, trigger point pressure algometry, range of motion assessment, and responses to standardized pain and psychological questionnaires were used as outcome measures; patients returned for follow-up assessment at 2 weeks, 1 month, 2 months, and 3 months post injection. After 3 months, all patients were offered participation in an open-label extension of the study. Effect sizes were calculated to index treatment effects among the intent-to-treat population; individual time series models were computed for average pain intensity. RESULTS: The 23 participants reported experiencing headache on a near-daily basis (average of 27 days/month). Compared with placebo, patients in the BT-A group reported greater reductions in headache frequency during the first part of the study (P = .013), but these effects dissipated by week 12. Reductions in headache intensity over time did not differ significantly between groups (P = .80; maximum d = 0.13), although a larger proportion of BT-A patients showed evidence of statistically significant improvements in headache intensity in the time series analyses (62.5% for BT-A vs 30% for placebo). There were no differences between the groups on any of the secondary outcome measures. CONCLUSIONS: The evidence for BT-A in headache is mixed, and even more so in CTTH. However, the putative technique of injecting BT-A directly into the ubiquitous MTPs in CTTH is partially supported in this pilot study. Definitive trials with larger samples are needed to test this hypothesis further.
PMID: 19178577 [PubMed - indexed for MEDLINE]
Headache. 2005 Apr;45(4):350-4.
The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine.
Ashkenazi A, Young WB.
Department of Neurology, Jefferson Headache Center, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
OBJECTIVE: To evaluate the effect of GONB, with or without trigger point injection (TPI), on dynamic mechanical (brush) allodynia (BA) and on head pain in migraine. Background.-Patients with migraine often have cutaneous allodynia that is related to sensitization of central pain neurons. Greater occipital nerve block (GONB) is an effective treatment for migraine headache; however, its effect on cutaneous allodynia in migraine is unknown. METHODS: We studied patients with migraine and BA who were treated with GONB with or without TPI. Demographic data, migraine history, and headache features were documented. Allodynia was evaluated using a structured questionnaire and by applying a 4 x 4-inch gauze pad to skin areas in the trigeminal and cervical dermatomes. Degree of allodynia (the allodynia score) was measured on a 100-mm visual analog scale (VAS) before treatment and 10 and 20 minutes thereafter. Headache levels were assessed using an 11-point verbal scale. Allodynia scores, as well as headache levels, before and after treatment were compared. RESULTS: Nineteen patients were studied. Mean age was 43.6+/-11.8 years. Twenty minutes after treatment, headache was reduced in 17 patients (89.5%) and did not change in 2 (10.5%). The average headache level was 6.53 before treatment and 3.47, 20 minutes after it. The average allodynia score decreased after 20 minutes in all patients. Average allodynia score per site was reduced by 18.69 mm and 13.74 mm in the trigeminal and cervical areas, respectively. There was a positive correlation between allodynia index, obtained through the questionnaire, and allodynia score, obtained by examination. CONCLUSION: GONB, with or without TPI, reduced both head pain and brush allodynia in this migraine patient group.
PMID: 15836572 [PubMed - indexed for MEDLINE]
Patients with Transformed Migraines frequently report a vascular quality, that exhibits a throbbing nature. In some cases, it can be difficult to distinguish between tension-type headaches and TM. These headaches are also identical to headaches frequently seen in patients with TMD or temporomandibular dysfunction. The history of headaches beginning in teen years and usually women fit the profile of TMD sufferers. There is a theory that all headaches are a combination of neurovascular and muscular headache pain. In this view of headaches the muscular or tension-type headache can trigger the vascular (or neurogenic) headache and the Vascular (or neurogenic ) headache can serve trigger the muscular headache. This theory always fits headaches arising from the trigeminal nervous system because it controls meningeal blood flow and masticatory muscles.
These headaches usually respon beautifully to treatment with a neuromuscular orthotic which can frequently eliminate the majority of pain. Some patients, especially those with long standing pain have developed myofascial trigger points that are not completely relieved by TENS and an orthotic. Those patients frequently can be helped by manual trigger point therapy, trigger point injections and/or nerve blocks to break up myofascial trigger points.
Unfortunately clinical studies have shown that almost 80% of these patients overuse symptomatic medications. This medication over-use can frequently increase migraine occurrence. The development of Medication Overuse Headache (MOH), also known as Rebound Headache is often seen with daily use of analgesics, either prescription or over-the-counter. Other risk factors for TM or CM include high life stress (as seen in TMJ or TMD patients), snoring and /or sleep apnea a TMJ disorder according to the NHLBI (http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf), head injury and history of orofacial trauma including wisdom teeth extraction and/or orthodontics (especially involving 4 bicuspid extraction).
Depression and anxiety are features shared by patients with Migraine, TMJ disorders, Tension-type headaches and Chronic Daily Headaches. Healthy lifestyle habits including sleeping, eating and exercising are important for all of these disorders. The typical neurologist will prescribe a variety of preventive therapies including Antidepressant and Anticonvulsant medications for transformed Migraine with a goal of reverting the headaches back from daily to episodic attacks. The Neuromuscular Dentist approach is to eliminate the myofascial pain by use of TENS and a neuromuscular orthotic and eventually eliminate the nociceptive input to the brain to eliminate the original migraineor vascular headache. The original migraine is usually a result of unhealthy neuromuscular input from the trigeminal nerve or airway collapse at night due to uderlying jaw pathology that leads to snoring, sleep apnea and upper airway resistance syndrome (sleep distrubance known to cause/promote fibromyalgia)
The use of triggr point infections is a way to hasten recovery when utilizing neuromuscular dentistry. An article in The Journal of Neurology, Neurosurgery and Psychiatry examined the effect of greater occipital nerve blocks and trigger point injections on Transformed Migraine (pubmed abstract below). The article compared these proceedures with and without use of triamcinolone which the authors concluded was unnecessary for the therapeutic effect. The therapeutic effect was impressive, there was immediate reduction in pain (3.2 points) and neck pain was reduced(1.5 points) and resulted in 2.7/3.8 headache free days. Th results were equal with or without the steroid. The use of anaesthetic injections to turn off migraine pain is effective for a short period of time but when combined with neuromuscular dentistry and the use of TENS and an orthotic to prevent recurrence of the problem can be part of a long term correction of this difficult problem.
Another article in Cranio (pubmed abstract below) "Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches." compared treatment of myofascial trigger points with three different methods.They found that " Statistically, all the groups showed favorable results for the evaluated requisites" "Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory." The treatment of myofascial trigger points successly treated the headaches. Breaking up the trigger points with the injection or the needle is effecteive without botulinum toxin or steroid use. Use of manual medicine, myotherapy and /or massage will also brek-up trigger points. Regardless of the method of eliminating the trigger points long term relief will depend on eliminating the noxious input to the trigeminal nervous system for long term relief. The use of the diagnostic neuromuscular dentistry orthotic is essential for most patients wanting to avoid a lifetime of drug use to treat the condition.
Yet another study in Headache (pubmed abstract below) "Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study." found very significant relief of headache pain of ETTH, Episodic Tension-Type Headaches by treatment of Cervical Myofacial Trigger Points. The study showed that trigger point injection with saline gave good results for up to 12 weeks where the Botox results did last for longer periods. Again this is a case calling for combination therapy of a Neuromuscular dentistry diagnostic orthotic and trigger point injections. Utilizing the combination should cause long term elimination of myofascial trigger points. Many patients will nor require the trigger point injections but they are helpful for difficult cases and to decrease treatment time with the diagnostic orthotic.
A diagnostic orthotic is used in Neuromuscular Dentistry (http://www.sleepandhealth.com/neuromuscular-dentistry) to eliminate pain and symptoms prior tolong term correction. This 2 phase treatment protocol allows patient neuromuscular stabilization and pain relief before making any irreverible occlusal changes.
One additional PubMed article is included below "The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine." which evaluated the effect of Greater Occipital Nerve Block on Migraine and
allodynia. Allodynia is when a stimulus that is not normally perceived as painful causes pain. The study had 19 patients and 17 or almost 90% had headache relief. All 19 patients had relief of allodynia. Neuromuscular Dentists should learn to use trigger point injections and Greater Occipital Nerve Blocks as part of comprehensive phase 1 treatment with neuromuscular orthotics to increase pain relief. Long term relief without the chronic use of drugs is ideally and frequently attainable with Neuromuscular Dentistry.
The Las Vegas Institute now teaches stimulation of the Accesory Nerve (cranial nerve XI) along with the Trigeminal Nerve (cranial nerve V) when utilizing TENS to relax muscles i
J Neurol Neurosurg Psychiatry. 2008 Apr;79(4):415-7. Epub 2007 Aug 6.
Greater occipital nerve block using local anaesthetics alone or with triamcinolone for transformed migraine: a randomised comparative study.
Ashkenazi A, Matro R, Shaw JW, Abbas MA, Silberstein SD.
Department of Neurology, Thomas Jefferson University, 111 South 11th Street, Suite 8130, Philadelphia, PA 19107, USA. avi.ashkenazi@jefferson.edu
OBJECTIVE: To determine whether adding triamcinolone to local anaesthetics increased the efficacy of greater occipital nerve block (GONB) and trigger-point injections (TPIs) for transformed migraine (TM). METHODS: Patients with TM were randomised to receive GONB and TPIs using lidocaine 2% and bupivacaine 0.5% + either saline or triamcinolone 40 mg. We assessed the severity of headache and associated symptoms before and 20 minutes after injection. Patients documented headache and severity of associated symptoms for 4 weeks after injections. Changes in symptom severity were compared between the two groups. RESULTS: Thirty-seven patients were included. Twenty minutes after injection, mean headache severity decreased by 3.2 points in group A (p<0.01) and by 3.1 points in group B (p<0.01). Mean neck pain severity decreased by 1.5 points in group A (p<0.01) and by 1.7 points in group B (p<0.01). Mean duration of being headache-free was 2.7+/-3.8 days in group A and 1.0+/-1.1 days in group B (p = 0.67). None of the outcome measures differed significantly between the two groups. Both treatments were well tolerated. CONCLUSIONS: Adding triamcinolone to local anaesthetics when performing GONB and TPIs was not associated with improved outcome in this sample of patients with TM.
PMID: 17682008 [PubMed - indexed for MEDLINE]
Cranio. 2009 Jan;27(1):46-53.
Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches.
Venancio Rde A, Alencar FG Jr, Zamperini C.
Marquette University School of Dentistry TMD and Orofacial Pain, P.O. Box 1881 Milwaukee, WI 53201-1881, USA.
Trigger point injections with different solutions have been studied mainly with regard to the management of myofascial pain (MFP) patient management. However, few studies have analyzed their effect in a chronic headache population with associated MFP. The purpose of this study was to assess if trigger point injections using botulinum toxin, lidocaine, and dry-needling injections for the management of local pain and associated headache management. Forty-five (45) myofascial pain patients with headaches that could be reproduced by activating at least one trigger point, were randomly assigned into one of the three groups: G1, dry-needling, G2, 0.25% lidocaine, at 0.25% and G3 botulinum toxin and were assessed during a 12 week period. Levels of pain intensity, frequency and duration, local postinjection sensitivity, obtainment time and duration of relief, and the use of rescue medication were evaluated. Statistically, all the groups showed favorable results for the evaluated requisites (p < or = 0.05), except for the use of rescue medication and local post injection sensitivity (G3 showed better results). Considering its reduced cost, lidocaine could be adopted as a substance of choice, and botulinum toxin should be reserved for refractory cases, in which the expected effects could not be achieved, and the use of a more expensive therapy would be mandatory.
PMID: 19241799 [PubMed - indexed for MEDLINE]
Headache. 2009 May;49(5):732-43. Epub 2008 Oct 24.
Botulinum toxin a in the treatment of chronic tension-type headache with cervical myofascial trigger points: a randomized, double-blind, placebo-controlled pilot study.
Harden RN, Cottrill J, Gagnon CM, Smitherman TA, Weinland SR, Tann B, Joseph P, Lee TS, Houle TT.
Center for Pain Studies, Rehabilitation Institute of Chicago, 446 E. Ontario, Chicago, IL 60611, USA.
OBJECTIVE: To evaluate the efficacy of botulinum toxin A (BT-A) as a prophylactic treatment for chronic tension-type headache (CTTH) with myofascial trigger points (MTPs) producing referred head pain. BACKGROUND: Although BT-A has received mixed support for the treatment of TTH, deliberate injection directly into the cervical MTPs very often found in this population has not been formally evaluated. METHODS: Patients with CTTH and specific MTPs producing referred head pain were assigned randomly to receive intramuscular injections of BT-A or isotonic saline (placebo) in a double-blind design. Daily headache diaries, pill counts, trigger point pressure algometry, range of motion assessment, and responses to standardized pain and psychological questionnaires were used as outcome measures; patients returned for follow-up assessment at 2 weeks, 1 month, 2 months, and 3 months post injection. After 3 months, all patients were offered participation in an open-label extension of the study. Effect sizes were calculated to index treatment effects among the intent-to-treat population; individual time series models were computed for average pain intensity. RESULTS: The 23 participants reported experiencing headache on a near-daily basis (average of 27 days/month). Compared with placebo, patients in the BT-A group reported greater reductions in headache frequency during the first part of the study (P = .013), but these effects dissipated by week 12. Reductions in headache intensity over time did not differ significantly between groups (P = .80; maximum d = 0.13), although a larger proportion of BT-A patients showed evidence of statistically significant improvements in headache intensity in the time series analyses (62.5% for BT-A vs 30% for placebo). There were no differences between the groups on any of the secondary outcome measures. CONCLUSIONS: The evidence for BT-A in headache is mixed, and even more so in CTTH. However, the putative technique of injecting BT-A directly into the ubiquitous MTPs in CTTH is partially supported in this pilot study. Definitive trials with larger samples are needed to test this hypothesis further.
PMID: 19178577 [PubMed - indexed for MEDLINE]
Headache. 2005 Apr;45(4):350-4.
The effects of greater occipital nerve block and trigger point injection on brush allodynia and pain in migraine.
Ashkenazi A, Young WB.
Department of Neurology, Jefferson Headache Center, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA.
OBJECTIVE: To evaluate the effect of GONB, with or without trigger point injection (TPI), on dynamic mechanical (brush) allodynia (BA) and on head pain in migraine. Background.-Patients with migraine often have cutaneous allodynia that is related to sensitization of central pain neurons. Greater occipital nerve block (GONB) is an effective treatment for migraine headache; however, its effect on cutaneous allodynia in migraine is unknown. METHODS: We studied patients with migraine and BA who were treated with GONB with or without TPI. Demographic data, migraine history, and headache features were documented. Allodynia was evaluated using a structured questionnaire and by applying a 4 x 4-inch gauze pad to skin areas in the trigeminal and cervical dermatomes. Degree of allodynia (the allodynia score) was measured on a 100-mm visual analog scale (VAS) before treatment and 10 and 20 minutes thereafter. Headache levels were assessed using an 11-point verbal scale. Allodynia scores, as well as headache levels, before and after treatment were compared. RESULTS: Nineteen patients were studied. Mean age was 43.6+/-11.8 years. Twenty minutes after treatment, headache was reduced in 17 patients (89.5%) and did not change in 2 (10.5%). The average headache level was 6.53 before treatment and 3.47, 20 minutes after it. The average allodynia score decreased after 20 minutes in all patients. Average allodynia score per site was reduced by 18.69 mm and 13.74 mm in the trigeminal and cervical areas, respectively. There was a positive correlation between allodynia index, obtained through the questionnaire, and allodynia score, obtained by examination. CONCLUSION: GONB, with or without TPI, reduced both head pain and brush allodynia in this migraine patient group.
PMID: 15836572 [PubMed - indexed for MEDLINE]
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