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Saturday, April 25, 2015


Are my headaches caused by TMJ?  
Headache Relief from BOTOX Injections is Diagnostic of a TMJ/TMD Disorder.
Edited from article in www.ThinkBetterLife.com

Patients frequently want to know whether their migraines or chronic daily headaches are caused by TMJ disorders.   This depends on how you differentiate  TMJ and/or  TMD disorders from headaches and migraines if the pain symptoms are identical.   The TMJ (Jaw Joint) is the TemporoMandibular Joint, TMD stands for TemporoMandibular Disorder.  The term TMJ often creates confusion in medical profesions, especially dentists who believe that TemporoMandibular Joints have to be clicking or poppping for a patient to be diagnosed with a TMJ disorder.  Diagnosing TMD or TemporoMandibular Dysfuction Syndrome requires examining  the entire complex of muscles, joints, teeth, habits, nervous system and understanding the complex underlying physiology of the entire system.

I have seen patients whose headaches are very easy to treat but they never had complete evaluation becaause they were told their headaches were not TMJ or TMD because there were no joint sounds or locking.  Patients can be critically deprived of proper treatment due to lack of apprpriate diagnosis.

TMD or TemporoMadibular Dysfunction includes the TMJoint, The joint capsule,  the muscles, the teeth, the periodontal ligaments,  the sinus linings, the tongue and its connections to the hyoid bone and associated muscles and ligaments, The posterior cervical muscles, the upper cervical spine including the atlas and axis vertebrae,the airway, the ears and most importantly the Trigeminal  Nervous System.
I will explain what the connection of TMJ to Headaches initially and at the end of this article how TMD treatment with a Diagnostic Neuromuscular Orthotic is an essential component in the diagnosis and treatment of all headache patients.
All headache specialists agree that the Trigeminal Nervous System is involved in almost 100% of all headaches. Specifically, two components of the Trigeminal Nerve are of critical importance to headache patients. The first is the Tigeminalvascular System which is the critical nervous component of all Migraine and Vascular Headaches as well as all autonomic Cephalgias. It controls the blood flow to the anterior two thirds of the brain thru the meninges or dura of the brain.
Most migraine preventive and treatment medications address the TrigeminoVascular System and the Trigeminal-Cervico Complex.
The second Trigeminal component is the Trigemino- Cervico Complex which is connected to almost all types of headaches including tension headaches, cervicogenic headaches and chronic daily headaches and more importantly is responsible for CENTRAL SENSITIZATION. Central Sensitization is the key connection that connects headaches and Fibromyalgia and other chronic pain syndromes.  
“The nociceptive (painful input) inflow from the meninges to the spinal cord is relayed in brainstem neurones of the trigemino-cervical complex (TCC). Two important mechanisms of pain transmission are the convergence of nociceptive trigeminal and cervical afferents and sensitization of trigemino-cervical neurones. ” (Schmerz. 2004 Oct;18(5):404-10.)
The same article also stated “These mechanisms have clinical correlates such as hyperalgesia, allodynia, spread and referral of pain to trigeminal or cervical dermatomes."  Trigemino-cervical complex neurones act as "integrative relay neurones between peripheral and central pain mechanisms. The understanding of these mechanisms has implications for the understanding of the clinical phenomenology in primary headache syndromes and the development of therapeutical options.”
The Central Nervous System thru the Trigeminal nerves causes referred pain and hyperalgesia, an increased sensitivity to pain, which may be caused by damage to nociceptors or peripheral nerves.
Dermatones are actually road maps of where different nerves go, understanding where nerves come from and go to is essential in diagnosing what processes are causing pain.
Peripheral treatment of Migraine, Tension Headache, Chronic Daily Headache and Chronic Migraine with Botox is currently in vogue and should be considered an important diagnostic procedure as well as a treatment procedure. When Botox is administered to Trigeminally innervated muscles and gives substantial relief it should be considered diagnostic proof of a TMD problem.  This is especially true in patients diagnosed with fibromyalgia,  MPD or Myofascial Pain and Dysfunction problems.  
While there is nothing wrong with injecting Botulinum Toxin every three months into headache and migraine patients if it relieves their symptoms and improves their quality of life it is ridiculous to ignore the underlying causes necessitating use of BOTOX.  Our bodies are not designed or evolved to require BOTOX injections but need them due to failure to achieve healthy homeostasis of physiologic systems.
Relief of Migraine and other headaches by BOTOX should be considered proof of the existence of a TMD disorder.  
The Trigeminal Nerve is often called the Dentist’s Nerve, it innervates all of the pulpal tissue of the teeth as well as the periodontal ligaments (PDL). The PDL has at least 29 known nerve receptors and is the largest input to the proprioceptive system of the human body. The Trigeminal dwarfs input from the middle ear especially after impulses are amplified inthe Reticular Activating System of the brain.  
The trigeminal nerve also innervates the Jaw Joints or TMJoints, the joint capsules and the retrodiscal lamina of the TMJoints where most primary TMJ pain originates. Referred pain to the TMJoint can come from Trigeminally innervated masticatory muscles including the masseter muscles, the temporalis muscles, the medial pterygoid muscles the lateral pterygoid muscles, the diagatric muscles and the very specialized muscles that tense the ear drum (Tensor Veli Tympani) and the muscle that opens and closes the eustacian tubes the Tensor Veli Palatini.
Referred pain to the TMJoint area can also be referred fron neck and shoulder musculature via the Trigemino-Cervical Complex.  The upper cervical musculature should always be considered as an intimate component of the masticatory system and be evaluated in TMJ and/or TMD patients.
The tongue is also partially innervated by the Trigeminal Nerve and an extremely important function of the Trigeminal Nerve is to maintain a patent airway. The National Heart Lung and Blood Institute (NHLBI) of the NIH wrote an incredibly important report “The Cardiovascular and Sleep Related Consequences of TemporoMandibular Disorders” It emphasizes the effects of airway on a wide variety of problems. Sleep Apnea is a TMD problem or Jaw Problem, the most important function of our jaws, teeth tongue and muscles is to maintain an airway, essential for life.
Forward head posture is implicated in almost all chronic head and neck problems and is actually largely a response to diminished airway. A more accurate description would be a forward neck posture with excessive rotation at Atlas-Axis-Occipital Joints. This airway head position connection is the link to all chiropractic patients and TMD patients. As long as forward head posture is uncorrected adverse mechanical forces will be affecting the spine and posture. Atlas Orthoganol Chiropractic and NUCCA Chiropractic address this connection concentrating on the Occipital -Atlas-Axis connections which they feel is the primary  key to successful treatment.
The effect of the Trigeminal nerve including TrigeminoVascular and Trigemino-Cervico Complexes is that of  variable nociceptive and proprioceptive input into our CNS or Central Nervous System. In computer language chronic pain is an I/O error or input/uotput error. In English, GARBAGE IN-GARBAGE OUT!  Too much Nociceptive input will create temporary and eventually premanent changes in brain function.  Our Brain is our computer and nociceptive and garbled input to the body creates biochemical changes in our brain, at one threshold they cause pain at a higher or more continuous level they cause chronic pain and at their worst they cause Central Sensitiztion or a meltdown of normal fuction with creation of Hyperalgesia (increased pain response) and Allodynia (inappropriate pain response). The use of Botox TOXIN is to disconnect the Trigeminal Nerve from the Trigeminal Muscles. If it improves headache it is proof of the TMD disorder.
The most Ethical approach to these problems is the use of a Neuromuscular Diagnostic Orthotic to correct physiologic function of the masticatory system, decrease trigminal nociception, to create homeostasis of the proprioceptive systems, decrease Central Sensitization, correct airway and posture and to remove adverse mechanical forces to the cervical spine and to the entire spinal structure.
When the neuromuscular diagnostic orthotic is used many patients respond extremely favorably and utilization of dangerous medications is reduced or eliminated. The frequency of physical therapy, massage therapy, chiropractic and osteopathic adjustments is reduced and the overall quality of life is improved.  This is due to the unique ability of the diagnostic orthotic to change input to the brain thru the Trigeminal Nervous System.
Patients who respond positively to treatment with a neuromuscular diagnostic orthotic can move forward with  definitive treatment or have long term removable orthotics made.  Patients can titrate the amount of time they wear removable orthotics based on their symptoms.  
The adaptability of the human body is great and the joints and muscles can adapt to less than perfect physiology and position but this results in excess nociception into the CNS and can result in Central Sensitization.   There are certain publications such as "Treating TMDs with Permanent Mandibular Repositioning: is it Medically Necessary?" by  Charles S. Greene, DDS, Ales Obrez, DMD, PhD that use adaptability as a reason not to create permanent changes in the bite for TMD.   
The conclusion is any position, no matter how awful is always correct because of adaptability.  You can change the position but not for TMD.  
The arcticle states " The continuing adaptability of the teeth, muscles and TMJs throughout life is described in terms of homeostasis, leading to the conclusion that each person current TMJ position is biologically correct. Therefore, that position does not need to be changed as part of a TMD treatment protocol. This means that irreversible treatment procedures such as equilibration, orthodontics, full mouth reconstruction and orthognathic surgery cannot be defended as being medically necessary.
Dr Greene has a long history of working with Insurance companies to deny patients legitimate coverage.  In this paper Dr Greens wants to use insurance contract medical language used to deny claims and raise it to the level of science.  

The following is a footnote in the article:  "The term “medical necessity” appears often in the medical literature in regard to treating patients with various diseases/disorders. However, it is almost never defined in an operational manner. The authors were unable to find a complete or consistent definition for this term by searching medical dictionaries, PubMed, or various internet search engines (e.g., Google, Bing, Yahoo). Instead, the main source for the above list has been certain insurance company contracts, in which they inform doctors and hospitals about what will or will not be covered. The authors have modified those statements to develop the 6-point definition presented here. 
The article is correct in stating there is adaptability but nervous system adaptability (or lack) creates central sensitization.
There are many aspects to treatment of TMJ disorders and this article is meant to address just the treatment effects of diagnostic orthotics.  Diagnostic Orthotics change jaw position and joint position but long term treatment is a clinical decision made by doctors and their patients together.
Each patient is in essence a clinical study of one. This is evidenced based medicine but it is the evidence obtained by evaluating and treating a single individual. There is an enormous benefit to prospective studies involving hundreds of patients to give us evidenced based approaches to fit populations. Unfortunately, the field of TMD has so many variables that the most efficatious method to study an individual is to do a clinical study that includes all of the variable unique to this specific patient. In utilizing a Neuromuscular Diagnostic Orthotic we accomplish that goal.
The patient can discontinue the non-invasive treatment at any time but if treatment improves symptoms in a life changing way the patient can elect to make definitive changes utilizing a position that has been shown to be effective and therapeutic.

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posted by Dr Shapira at 6:41 AM

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