Dr. Shapira's Chicago Headache Blog

* required |Privacy Policy

Saturday, April 3, 2010

Neuromuscular Dentistry: The basic Premises and history of the science of Neuromuscular Dentistry

Much of this material is taken from my delanydentalcare.com website and from Sleep and Health's article on Neuromuscular Dentistry http://www.sleepandhealth.com/neuromuscular-dentistry which I highly suggest you read for a more detailed explanation of neuromuscular dentistry science and physiological principles.

Neuromuscular Dentistry is founded on the basic premise that healthy physiologic muscle function is basic to all of dentistry and medicine. The health of the underlying neurological systems, particularly those of the Trigeminal Nerve including the sympathetic and parasympathetic divisions. A corollary to this concept of healthy nerves and muscles is: Doctors do not heal their patients but rather they remove the impediments to healing and the body heals itself.

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 (and pathological muscle adaptation) during closure. This means that there are no noxious contacts to the teeth that are 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.

I founded Ihateheadaches.org, as a resource dedicated to educating and assisting those in need of headache, migraine and TMD diagnosis and treatment.

Neuromuscular dentistry is one of the most exciting fields of dentistry. The history of dental treatment has always been mechanical and primarily involved in repairing diseased and damaged tissues. This changed in 1934 when Dr. Costen, an otolaryngologist, in St Louis, Missouri described a series of problems in denture patients that eventually grew to become know as TMD or TMJ disorders. True to the mechanical background of dentists, they treated these problems as mechanical problems.

Centric Relation was a major concept in the background of treatment of TMD (TMJ) disorders (temporomandibular disorders). Centric Relation was a terminal hinge point of the TM Joints as determined by manipulation of the lower jaw by the dentist. There is stgill a large group of doctors who cling to this concept. There have been over 26 different definitions of centric relation over the years.

Wikipedia defines centric relation as "In dentistry, centric relation is the mandibular jaw position in which the head of the condyle is situated as far superior and anterior as it possibly can within the mandibular fossa. This position is used when restoring edentulous patients with removable or either implant-supported hybrid or fixed prostheses. Because the dentist wants to be able to reproducibly relate the patient's maxilla and mandible, but the patient does not have teeth with which to establish his or her own vertical dimension of occlusion, another method has been devised to achieve this goal. The condyle can only be in the same place as it was the last time it was positioned by the dentist if it is consistently moved to the most superior and anterior position within the fossa."

The problem with the entire concept of centric relation is that it makes the musclesand nerves secondary players in occlusion. The treating doctors muscles become more important than the patients normal nerve and muscle physiology and function. This all changed due a giant in dentistry Dr Barney Jankelson considered the father of Neuromuscular Dentistry.

Dr. Barney Jankelson, a board certified prosthodontist (specialty dentist), changed dentistry by making the muscles and neuromusculqr function of patients the center of treatment. He realized that while mechanics were important in treatment of headaches, TMj disorders and other painful conditions, the underlying muscle physiology was most important. Dr. Jankelson (or Dr J) as his friends called him developed methods of relaxing muscles and measuring physiologic parameters . His work was done in Seattle, Washington now known world-wide as the birthplace of Neuromuscular dentistry. The method to create healthy musculature depended on a dental occlusion

Due to the Knowledge of Dr. J. and many other great innovators, neuromuscular dentistry became the preeminent treatment for TMJ problems.

There was a major split in dentistry with many dentists clinging to their outdated mechanical views. These dentists still believe that the jaw joint or the temporomandibular joint is the most important aspect of treatment . They consider themselves to be Centric Relation dentists. Centric relation is the description of a joint position. The fallacy of this belief is reflected in the fact that the definition of centric relation continuously changes, and there are over 20 different definitions. The main belief of this group is that the muscles of the treating dentist's hands know better where the patients jaw should function than the patient's own relaxed healthy muscles. There is a third group of dentists who do not believe in the physical nature of these disorders and believe that pschotherapy, medication and biofeedback are the best way to treat all headaches and TMJ problems. They do not believe that the teeth and occlusion are involved in the development of TMD problems or are useful in treating these problems. They believe it is primarily a psychological problem though they frequently do not communicate this fact to their patients.

Neuromuscular Dentistry recognizes that the muscles, bones, joints and nerves of the masticatory system are the same in the masticatory region as in other areas of the body and that creating a healthy system by eliminating pathological function is basic to health.

There are other greats in Neuromuscular Dentistry.

Dr. Jim Garry was a pedodontist who described how airway and facial development affected the normal formation of the jaws and face. He was a great advocate of breastfeeding, and his work has changed the lives of tens of thousands of children.

Dr. Norman Thomas is an anatomist, physiologist and dentist who understood the science behind neuromuscular dentistry and how it related to total body health and posture. He is the brilliant man that still enables clinicians to integrate their clinical skills with the underlying basic science. He continues to do some of the most important work in all of dentistry at the Las Vegas Institute (LVI).

Robert Jankelson, Barney's son, carried on his father's work and wrote the first textbook on neuromuscular dentistry.

Janet Travell, who is one of the all time medical greats in the field of pain management and is known for her textbook Myofascial Pain and Dysfunction: A Trigger Point Manual. She was President Kennedy's personal physician. He had severe chronic pain and walked with a limp and cane due to war injuries. Dr. Travell changed his life by letting him live without severe pain.

Jackie Kennedy built the Rose Garden at the White House in her honor because Dr. Travell loved Roses.

I am Dr. Ira Shapira and I was fortunate to be students of these greats of neuromuscular dentistry. I have been practicing the art and science of neuromuscular dentistry for over 30 years . My partner Dr. Mark Amidei, has been with me for over 20 years and also practices using neuromuscular dentistry.

The Las Vegas Institute, considered the premier learning institute, was founded by Dr. Bill Dickerson. His background was from the Centric Relation mechanical school of thought but 10 years ago he had the great courage to abandon the outdated ideas and teach cosmetic reconstruction using neuromuscular ideals. Thousands of dentists around the world are now embracing the science of neuromuscular dentistry. Bill is one of the great men in cosmetic dentistry but he will be best remembered for his work in making neuromuscular dentistry available to the world. Dr Norman Thomas is now leading LVI in teaching and researching Neuromusclar dentistry. He is a great inspiration to his students who will represent the future of neuromuscular dentistry and research in this important field.

Traditional dentistry operates under the assumption that your jaw's acquired position is its optimum position. Neuromuscular dentistry, on the other hand is focused on finding the ideal position or range of positions for ideal health. This optimum position for your jaw is the basis for future work. This ideal position continually resets the neuromuscular system to a healthy physiologic condition.

My goal in utilizing Neuromuscular Dentistry is not just to treat a single tooth to solve a complex problem. Instead, we examine the entire neuromuscular and anatomical system of the head and neck in order to treat the whole patient, alleviating pain throughout the mouth and body.

We strive to treat the whole problem and give our patients a higher quality of life by aligning your jaw in the most comfortable position possible. Posture throughout the body is affected by the jaw and jaw function. The lower jaw acts like a counter balance for the skull as it sits atop of the spine much like the weights that are used in a doctors scale. You set the 50 and the 10 pound weights and the when you get the 1 pound weight perfectly adjusted the scale rests perfectly centered. If you move that weight even slightly in either direction the scale does not go slightly out of balance but rather it goes clunk. That is the effect disruptions in jaw function has on the entire body's postural balance. I tell my patients, You've been clunked.

Neuromuscular Dentistry;
Diagnostic and treatment modalities: There are two manufactures who make diagnostic equipment used by Neuromuscular Dentists, Myotronics and BioResearch. Myotronics was founded by Dr Barney Jankelson.

Warning!! All doctors that use these modalities do not practice neuromuscular dentistry. Some use the information as a baseline only!

MKG- Computerized Mandibular Scan
The mkg was invented by Dr. Barney Jankelson, DR. J, and it is designed to measure mandibular movement in 3 dimensions and track the jaw to understand both function and dysfunction. The name actually means study of mandibular movement. The name was changed to differentiate between neuromuscular dentistry and kinesiology, the study of movement elsewhere in the body. The scanner works by tracking a small magnet to the lower front teeth and tracking the magnets movement by sensors that do not touch the lower jaw. This allows the study of mandibular motion free of any interfering forces. Dr Shapira has been using an MKG for 28 years starting with an early model that utilized an ossciliscope to today's modern computerized scans. I The understanding based on ossciliscope findings have been verified by today's computers. Clinicians who learned on the ossciliscope usually have a deeper understanding than doctors learning on computers today. Today's computers do give a wealth of information that was not available in the past.

EMG or electromyography is utilized in conjunction with the MKG or CMS to evaluate the physiologic state and function of the masticatory (jaw) muscles and neck postural muscles. The EMG can be used to evaluate bilateral symmetry of the muscles, the health during rest and function, and can be used for incredibly accurate adjustments to the bite.

Emg is also used to measure the effectiveness of TENS in relaxing muscles. Neuromuscular dentistry typically uses bipolar adhesive skin electrodes that measure activity only. There is no discomfort involved during EMG testing. Effectiveness of muscle relaxation can be determined by EMG following use of TENS.

Dr Shapira and Dr Amidei have recently upgraed their myotronic equipment from the K6 to two new K7diagnostic systems.

TENS or transcutaneous electrical neural stimulation is at the heart of all neuromuscular dentistry. It is used to create a healthy relaxed state in unhealthy, diseased or spastic muscles. The Myomonitor is a specific type of TENS unit invented by Dr. Barney Jankelson that is used to relax masticatory and cervical musculature. The unit uses a very small electrical impulse to gently stimulate the muscles through a single synapse reflex (similar to the knee jerk done by physicians) repeatedly over an extended time. This action naturally relaxes the muscles. While some people don't think the process sounds natural I describe it as such because the repeated pulsing and relaxation pumps metabolic wastes out of the muscle cells and brings in blood with oxygen and nutrition, and the muscle relaxes as it heals versus the unnatural relaxation occurring by dumping chemicals or drugs into the system.

The pulses occur every 1.5 seconds and last only a 500th of a second. This time is set because it is the length of time it takes the cellular membrane to return to normal after stimulation. It is for this reason the muscles can be pulsed for an extended time without fatigue.

Borer associates have a similar TENS unit that is used for the same purposes but is slightly different in design. The slight differences usually do not matter, but for difficult long-term patients, each unit has its own peculiar advantages usually only appreciated by the very skilled and adept neuromuscular practitioner.

Both types of TENS are used in conjunction with the MKG and EMG to evaluate changes in mandibular position and function as the muscles are made healthier. Most problems are associated with long term accommodation pf muscle to less than ideal conditions. This results in a repetitive strain injury as the muscles must overcompensate for long periods of time.

The best way is to look at the diagnostic information gathered with these devices as aids that help the doctor make a more accurate diagnosis and plan effective treatment. If you go to the mall and look for a store, you will look up the store on the map and then look for the you are here arrow to figure out where you are in relation to where you are going. This information is vital to prevent treatment going in the wrong direction.

Transcranial neural transmitter modulation is a very unique type of TENS unit that is designed to stimulate the brain and create neurotransmitter changes in the brain similar to potent antidepressants without the chemical side effects.

Dr. Ira Shapira has been using this instrument as part of a diagnostic protocol to help understand and differentiate between peripheral disorders and problems arising from the CNS or central nervous system.

TENSing (Transcutaneous Electrical Neuromuscular Stimulation) muscles works out the lactic acid in your jaw muscles while working in fresh blood, oxygen, and nourishment for your jaw muscles. This helps relax your muscles and helps neuromuscular dentist Dr. Shapira to re-align your jaw to its relaxed neuromuscular rest position and establish an occlusion that lets the patients muscles return to a healthy state after use. The corrective alignment is usually done by a diagnostic orthotic. This allows initial treatment that is reversible until accurate diagnosis and successful phase 1 treatment is accomplished.

Phase 1 treatment is designed to find a functional position that stabilizes the jaw and allows healthy function in which the muscles naturally return to their relaxed state. Phase 2 treatment is long term stabilization with a more permanent orthotic cosmetic reconstruction orthodontic or surgical intervention. Avoidance of surgery is a top concern of Dr. shapira because there are so many complications related to surgery.

Neuromuscular dentist, Dr. Shapira, has been working with chronic head and neck pain patients for 30 years. His practice is dedicated to non-surgical alternatives to Temporomandibular Joint Dysfunction and drug-free pain management. He is certified to treat sleep apnea with FDA approved appliances as non-surgical alternatives to UP3 and Tracheotomy. He is a Diplomate of The American Board of Dental Sleep Medicine and TYhe American Academy of Pain Management. He understands the relation of jaw position and sleep apnea to all of the physical and biochemical disorder patients deal with. He has successfully treated hundreds of patients with a multitude of TM Joint problems, TMD and the myriad of related conditions. As a former sufferer of chronic pain, Dr Shapira made it a personal crusade to not only relieve his pain but to give patients a quality of life they never thought was possible.

Dr Shapira trained with Dr Janet Travell, the world's expert on myofascial pain and dysfunction and uses the techniques he learned from her to alleviate pain and restore normal function to his patients. Many experts consider fibromyalgia and myofascial dysfunction to be different subsets of the same disorder.

The I HATE Headaches website has a find a Dentist area that will continue to grow. If there is not a dentist in your area on the site currently contact Dr Shapira and he will help you locate a Neuromuscular Dentist in your area.

Labels: , , , , , ,

posted by Dr Shapira at 1:50 PM

Welcome to the iHATEheadaches website, please upgrade your Flash Plugin and enable JavaScript.