Dr. Shapira's Chicago Headache Blog

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Wednesday, February 17, 2016

Chicago Headache Relief: Addressing The Common Cause of all Headaches is Key

What All Headaches Have In Common: Migraines, Cluster Headaches, Chronic Daily Headaches, New Persistent Headaches Cluster Headaches

QUESTIONS AND ANSWERS ABOUT HEADACHES:
Question from Kasey in Pennsylvania: I always seem to have a headache that never 100% goes away, and it usually varies day to day. It can get worse by mid to the end of the day. I don't have bad jaw pain but could that be a culprit, can foods cause tension headaches?
Dr Shapira Reply: Dear Kasey,
I am sorry to hear you are spending your entire life in pain. I hope I can help ease your burden.
Most (almost 100%) of headaches are from Trigeminal Nervous System. The Trigeminal Nerve is also called the dentists nerve because it goes to the teeth, jaw muscles, jaw joints, sinuses, gums, and periodontal ligaments.
The Trigeminal nerve also controls blood flow into the anterior two thirds of the brain. The two main methods of causing headaches is referred muscle pain and vascular / neurogenic factors bot closely connected to jaw function.
Please visit my other site www.ThinkBetterLife.com to learn more.
I frequently see long distance patients and we make special scheduling arrangements.
Would you like me to have a team member contact you?
Ira L Shapira DDS
Diplomat, American Academy of Pain Management
Diplomate, American Board of Dental Sleep Medicine
Regent and Fellow, International College of CranioMandibular Orthopedics
Board Eligible, Academy of CranioFacial Pain
Chair, American Alliance of TMD Organizations
Kasey Response: How is it known almost 100% of headaches are caused from that nerve? Well i have had headaches for years and just in the past two years or year my jaw seems to have more tension now. When the headache gets bad or moderate i seem to really feel it in my jaw/facial area in a way but the headaches are always top of head, whole head, sometimes more localized and slightly migraine like and in my eyes. I am unsure if it is always sort of there or not. Can tmj really cause this?
I do not have bad jaw pain as i read some people talk about but i do have clicking popping, etc. I have read a lot about NDPH but i feel something is always causing the headache, maybe it can be from an overactive immune system in the cns but who knows. ( what i read ) mri's always normal had 3 so far in a span of years but never with contrast, never got nek mri or an mra
I guess I am lucky i don't get severe migraines.. I am thankful for that, msotly seem to get tension headaches that develop as the day goes on. Considering trying wobenzm, lots of fish oil, have tried ginger, willow bark, turmeric doesnt seem to do much. Haven't tried high dose riboflavin. Was on elavil in the past, also found i have lyme, which i am sure many have in them, candida, other co's. I feel the headache started before these, but who knows. Maybe candida can cause constant headaches?
I have it narrowed down to pathogens, constant inflammation, eyes (vertical heterophoria possibly?), needing an atlas adjustment (or regular chiro?), food sensitivity or tmj related like you mention. can something like the smart guard mouthguard help? (Prevents back teeth touching) can tmj or clenching in sleep be a secret cause of daily headaches? Can inflammation in the body / from the immune system cause constant headaches instead of arthritis? And can many people have a spinal misalignment and not know it that causes headache? Thank you!!
Where are these doctors located, is I Hate Headaches headache specialists?
Dr Shapira Response:
Excellent Questions! I am actually going to send a few PUBMED abstracts to explain.
It is generally known to all Neurologists and headache treatment doctors. Only one group of headaches includes trigeminal in their name. The Trigeminal Autonomic Cephalgias.
The Trigeminal nerve also controls blood flow to the anterior 2/3 of meninges of brain where it is cause of migraines. This quote is from the following abstract ". The mechanisms most likely to contribute to the pain phase of migraine require activation of trigeminal afferent signaling from the cranial meninges and subsequent relay of nociceptive information into the central nervous system in a region of the dorsal brainstem known as the trigeminal nucleus caudalis."
This abstract explains some connections
http://www.ncbi.nlm.nih.gov/pubmed/16082236
This abstract explains connection of Trigeminal Nervous System to Cervicogenic headaches. "The trigeminocervical nucleus is a region of the upper cervical spinal cord where sensory nerve fibers in the descending tract of the trigeminal nerve converge with sensory fibers from the upper cervical roots. This convergence of nociceptive pathways allows for the referral of pain signals from the neck to the trigeminal sensory receptive fields of the face and head as well as activation of the trigeminovascular neuroinflammatory cascade, which is generally believed to be one of the important pathophysiologic mechanisms of migraine. "
As to the question of how to find doctors to help with this problem. This is more difficult, but I strongly Rx that anyone looking for a Neuromuscular Dentist go to ICCMO.org.
I appreciate your feedback.
I established I Hate Headaches several years ago. It was originally to be resource but funding suffered when the economy collapsed. Many patients see me in Chicago but I can help you find a doctor in your area.
The connections to the atlas/ axis , immune system, posture, etc go and on and on.
The easiest method to thin about it is in terms of a automobile; If the engine, transmission , axels wheels etc are perfect the car runs great. If you get a flat tire but keep driving you will have four flats, bent axels, bad transmission and motor and not have a functioning car. Problems begin at the weakest link and spread as secondary problems across the body.
In different patients their are different weak points.
Ira L Shapira DDS
Diplomat, American Academy of Pain Management
Diplomate, American Board of Dental Sleep Medicine
Regent and Fellow, International College of CranioMandibular Orthopedics
Board Eligible, Academy of CranioFacial Pain
Chair, American Alliance of TMD Organizations

Question from Kasey: I am in Pennsylvania near XXXXXXXXX, unsure any are near me. So the jaw nerve can cause tension headache even without jaw pain? And it can cause constant headaches? I read an atlas adjustment can fix it, so should I look into that possibility first? I've also read about vertical heterophoria, that can cause headache too.
I ordered the smart guard and am thinking of trying the aqualizer. Could the aqualizer show if I have a misaligned jaw/bite or not? Do you use repositioning splints?
DR SHAPIRA RESPONSE:
Yes, the Trigeminal nerve can cause all kinds of problems even without jaw pain. Input from the trigeminal nerve has an enormous effect on the CNS.
Atlas Orthoganol and/or NUCCA chiropractors can correct the atlas- axis- occipital joint complex but stability of the axis may require an oral orthotic. The dents process of the atlas is the center of rotation for the jaw (quadrant theorem of Guzay).
Not sure what a smart guard is but the Aqualizer is excellent short term epecially if doing atlas orthoganol or NUCCA adjustments as it is self leveling. I often have patients wear them after A/O adjustment while traveling directly to my office.
vertical heterophoria is one of many visual disorders that relate to headache that is best addressed by a behavioral optometrist.
I utilize diagnostic neuromuscular orthotics at the start of treatment.
The Aqualizer won't show misalignment burt it may improve your symptoms if you are unbalanced.
THE AQUALIZER IS AN AMAZING LITTLE DEVICE THAT WAS INVENTED BY A FRIEND OF MINE DR MARTY LERMAN WHO WAS BRILLIANT. I used to review his scientific articles for him prior to being submitted for publication. The company is now run by his son Bob who has exciting plans for new products.
In my opinion, I would suggest searching out a ICCMO member for a neuromuscular evaluation.
Dr Shapira
posted by Dr Shapira at 7:59 AM 

Tuesday, December 29, 2015

Facial Pain Relief in Chicago: Expertise in Trigeminal Nervous System is needed for Effective Treatment of Facial Pain, Migraine and Chronic Daily Headaches

Chronic facial pain is often seen in a very different light than other chronic pains.  For a long time Atypical Facial Pain was considered a psychiatric diagnosis   It is been reclassified and is now considered a trigeminal nerve or other cranial nerve disorder.

This type of pain is frequently associated with long term suffering and frequent misdiagnosis.  I have been treating chronic atypical facial pain for over 30 years in my Gurnee and Highland Park offices.
To learn more visit my office websites;
Highland Park:  www.ThinkBetterLife.com
Gurnee:   www.DelanyDentalCare.com

The ICD 10 coding for atypical facial pain or persistent idiopathic facial pain is as follows.
13.18.4Persistent idiopathic facial pain [G50.1]G44.847  
Previously used termsAtypical facial pain

THE DESCRIPTION OF THIS PAIN IS VERY SIMPLE AND COULD EASILY BE A MYOFASCIAL OR TMD CONDITION.  IT IS CONSIDERED DIFFERENT THAN HEADACHES OR MIGRAINES

Description:

Persistent facial pain that does not have the characteristics of the cranial neuralgias described above and is not attributed to another disorder.

Diagnostic criteria:

  1. Pain in the face, present daily and persisting for all or most of the day, fulfilling criteria B and C
  2. Pain is confined at onset to a limited area on one side of the face1, and is deep and poorly localised
  3. Pain is not associated with sensory loss or other physical signs
  4. Investigations including x-ray of face and jaws do not demonstrate any relevant abnormalit

POSSIBLY THE BEST METHOD OF CLASSIFYING THESE PAINS MAY NOT BE THE DESCRIPTION OF THE PAIN BUT RATHER WHAT THE PAIN RESPONDS TO.


SPB Blocks have been used for years to treat headaches, migraines and other pain disorders.  Sluders neuralgia was origiinally described in 1908 but is sometimes considered the original TMJ diagnos prior to the diagnosis of Costen's syndrome.  

The diagnosis of contact point headaches also known as Anterior Ethmoid neuralgia, pterygopalatine ganglion neuralgia, Sluder's Neuralgia and sphenopalatine Ganglion neuralgia often presents as pain of unknown orgin .  It can respond to SPG Blocks but in general is very resistant to diagnosis.

This condition may be a nerve compression syndrome but it can spread pain anywhere in the opthalmic or maxillary divisions or the Trigeminal Nerve.

The pain follows a similar pattern as trigger points in pterygoid, masseter and temporalis muscles.  It can sometimes be relieved by decongestants such as Afrin that shrink the nasal tissues.

Neuromuscular Dentistry in conjunction with SPG Blocks, Trigger Point injections, Spray and Stretch, prolotherapy is still the most effective approach to chronic facial pain.

All work should begin with reversible therapy and permanent changes should only be done after extended relief of pain.

#ChicagoMigraines, #ChicagoContactHeadache, #ChicagoSPGBlock, #ChgicagoImprovingQualityof Life, #IllinoisFacialPain
posted by Dr Shapira at 1:22 PM 

Monday, December 21, 2015

Chronic Daily Headaches, Migraines, Cluster Headaches & Rebound Headaches . SPG Blocks Spell Relief and Prevention

Originally posted as a Blog on www.ThinkBetterLife.com
The SPG Block or Sphenopalatine Ganglion Block can be extremely effective at preventing and eliminating migraines. The Sphenopalatine Ganglion is part of the Autonomic Nervous System. It is the Largest Parasympathetic Ganglion and treatment with lidocaine has been shown to be very effective for treating a wide variety of chronic and acute pain syndromes including Migraine, Cluster Headache, Chronic Daily Headache, New Persistent headache, Rebound Headache, Sinus Pain, Trigeminal Neuralgia, Autonomic Cephalgias and many other disorders.  It is frequently used for medically refractory headaches where all other treatments have failed.  SphenoPalatine Ganglion Blocks are probably grossly undrutilized based on safety and cost effectiveness.
There are multiple routes of administration including through the nose and by intra-oral or suprazygomatic injection.
There are several new FDA approved devices for delivering SPG blocks intranasally. These include the Sphenocath, the Allevio and the TX360. The MiRX protocol is specifically designed to prevent and eliminate migraines. The use of cotton tipped applicators saturated with lidocaine, cocaine or other anesthetic has been utilized for many years.
The use of hollow tipped applicators allow a continual feeding mechanism for anesthetic that can easily be accomplished by most patients. This method is extremely cost effective and convenient for patients.
Self administration of SPG Blocks is the key to putting chronic pain patients back in control of their lives.
The injection techniques are most effective in turning off an acute attack. I recently taught a hands on course to neuromuscular dentists at the ICCMO meeting in San Diego several methods of delivering anesthetic to the Sphenopalatine Ganglion.
Self administered Sphenopalatine blocks have been used for multiple conditions including CRPS, Complex Regional Pain Syndrome of the lower extremity (PubMed abstract below), Post Dural Puncture Headache, to treat Tension Headache in pregnant patients, and for OroFacial Pain (PubMed abstract below).  The usefulness has been described of SPG blocks in Pain clinics as well (PubMed Abstract below)

Arch Phys Med Rehabil. 2005 Feb;86(2):335-7.

Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option.

Abstract

We report 2 cases of complex regional pain syndrome (CRPS) involving the lower extremity; in both, a sphenopalatine ganglion (SPGblock was performed as part of a pain management program. In the first case, a woman in her late twenties presented with CRPS in the left lower extremity that was inadequately controlled with typical oral medications. Sympathetic block of the extremity did not provide significant pain relief. However, a noninvasive sphenopalatine block with 4% tetracaine resulted in a 50% reduction in pain level. The patient was shown how to self-administer the sphenopalatine block and was provided with exercises and therapy to help improve her functional status. The second case involved a woman in her mid forties with CRPS in the right lower extremity that was partially controlled with oral medications. The patient experienced a 50% reduction in pain level when SPG block with 4% tetracaine was given. Further study is needed to determine the effects of SPG blocks on symptoms related to chronic regional pain syndrome.
PMID:
15706564
[PubMed – indexed for MEDLINE]
Cranio. 1995 Jul;13(3):177-81.
Int J Obstet Anesth. 2014 Aug;23(3):292-3. doi: 10.1016/j.ijoa.2014.04.010. Epub 2014 May 10.

Transnasal topicalsphenopalatine ganglion block to treat tension headache in a pregnant patient.

Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.

Abstract

The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.
PMID:
8949858
[PubMed – indexed for MEDLINE]
Clin J Pain. 1990 Jun;6(2):131-6.
Am J Emerg Med. 2015 Nov;33(11):1714.e1-2. doi: 10.1016/j.ajem.2015.03.024. Epub 2015 Mar 14.

Transnasalsphenopalatine ganglion block for the treatment of postdural puncture headache in the ED.

Sphenopalatine ganglion block: clinical use in the pain management clinic.

Abstract

Clinical experience with the sphenopalatine ganglion (SPG) block combined with a review of prior studies led to conducting a retrospective evaluation of four patients with chronic pain treated with the SPG block. The review of case reports suggests the usefulness of SPG blocks in the pain management clinic.

Comment in

Headache. 2013 Jul-Aug;53(7):1183-90. doi: 10.1111/head.12148. Epub 2013 Jun 28.

Cluster headache: potential options for medically refractory patients (when all else fails).

Abstract

The most evidence exists for mixed anesthetic/steroid occipital nerve blocks (which are also useful in non-refractory patients), deep brain stimulation, sphenopalatine ganglion (SPG) blocks, SPG radiofrequency ablation, and SPG stimulation with the Autonomic Technologies, Inc (ATI) SPG Neurostimulator, the latter approved in the European Union and reimbursed in several countries.

posted by Dr Shapira at 9:18 AM 

Thursday, December 17, 2015

Self Administration of SPG Blocks by Patients. The Ultimate in Personal Medicine for Pain

This was originally published as a blog post on http://www.ThinkBetterLife.com.  There are multible testimonials on youtube about the effectiveness of sphenopalatine ganglion blocks.  https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg


The SPG Block or Sphenopalatine Ganglion Block can be extremely effective at preventing and eliminating migraines. The Sphenopalatine Ganglion is part of the Autonomic Nervous System. It is the Largest Parasympathetic Ganglion and treatment with lidocaine has been shown to be very effective for treating a wide variety of chronic and acute pain syndromes including Migraine, Cluster Headache, Chronic Daily Headache, New Persistent headache, Rebound Headache, Sinus Pain, Trigeminal Neuralgia, Autonomic Cephalgias and many other disorders.  It is frequently used for medically refractory headaches where all other treatments have failed.  SphenoPalatine Ganglion Blocks are probably grossly undrutilized based on safety and cost effectiveness.
There are multiple routes of administration including through the nose and by intra-oral or suprazygomatic injection.
There are several new FDA approved devices for delivering SPG blocks intranasally. These include the Sphenocath, the Allevio and the TX360. The MiRX protocol is specifically designed to prevent and eliminate migraines. The use of cotton tipped applicators saturated with lidocaine, cocaine or other anesthetic has been utilized for many years.
The use of hollow tipped applicators allow a continual feeding mechanism for anesthetic that can easily be accomplished by most patients. This method is extremely cost effective and convenient for patients.
Self administration of SPG Blocks is the key to putting chronic pain patients back in control of their lives.
The injection techniques are most effective in turning off an acute attack. I recently taught a hands on course to neuromuscular dentists at the ICCMO meeting in San Diego several methods of delivering anesthetic to the Sphenopalatine Ganglion.
Self administered Sphenopalatine blocks have been used for multiple conditions including CRPS, Complex Regional Pain Syndrome of the lower extremity (PubMed abstract below), Post Dural Puncture Headache, to treat Tension Headache in pregnant patients, and for OroFacial Pain (PubMed abstract below).  The usefulness has been described of SPG blocks in Pain clinics as well (PubMed Abstract below)

Arch Phys Med Rehabil. 2005 Feb;86(2):335-7.

Complex regional pain syndrome involving the lower extremity: a report of 2 cases of sphenopalatine block as a treatment option.

Abstract

We report 2 cases of complex regional pain syndrome (CRPS) involving the lower extremity; in both, a sphenopalatine ganglion (SPGblock was performed as part of a pain management program. In the first case, a woman in her late twenties presented with CRPS in the left lower extremity that was inadequately controlled with typical oral medications. Sympathetic block of the extremity did not provide significant pain relief. However, a noninvasive sphenopalatine block with 4% tetracaine resulted in a 50% reduction in pain level. The patient was shown how to self-administer the sphenopalatine block and was provided with exercises and therapy to help improve her functional status. The second case involved a woman in her mid forties with CRPS in the right lower extremity that was partially controlled with oral medications. The patient experienced a 50% reduction in pain level when SPG block with 4% tetracaine was given. Further study is needed to determine the effects of SPG blocks on symptoms related to chronic regional pain syndrome.
PMID:
15706564
[PubMed - indexed for MEDLINE]
Cranio. 1995 Jul;13(3):177-81.
Int J Obstet Anesth. 2014 Aug;23(3):292-3. doi: 10.1016/j.ijoa.2014.04.010. Epub 2014 May 10.

Transnasal topical sphenopalatine ganglion block to treat tension headache in a pregnant patient.

 

Sphenopalatine ganglion block: a safe and easy method for the management of orofacial pain.

Abstract

The sphenopalatine ganglion (SPG) block is a safe, easy method for the control of acute or chronic pain in any pain management office. It takes only a few moments to implement, and the patient can be safely taught to effectively perform this pain control procedure at home with good expectations and results. Indications for the SPG blocks include pain of musculoskeletal origin, vascular origin and neurogenic origin. It has been used effectively in the management of temporomandibular joint (TMJ) pain, cluster headaches, tic douloureux, dysmenorrhea, trigeminal neuralgia, bronchospasm and chronic hiccup.
PMID:
8949858
[PubMed - indexed for MEDLINE]
Clin J Pain. 1990 Jun;6(2):131-6.
Am J Emerg Med. 2015 Nov;33(11):1714.e1-2. doi: 10.1016/j.ajem.2015.03.024. Epub 2015 Mar 14.

Transnasal sphenopalatine ganglion block for the treatment of postdural puncture headache in the ED.

Sphenopalatine ganglion block: clinical use in the pain management clinic.

Abstract

Clinical experience with the sphenopalatine ganglion (SPG) block combined with a review of prior studies led to conducting a retrospective evaluation of four patients with chronic pain treated with the SPG block. The review of case reports suggests the usefulness of SPG blocks in the pain management clinic.

Comment in

Headache. 2013 Jul-Aug;53(7):1183-90. doi: 10.1111/head.12148. Epub 2013 Jun 28.

Cluster headache: potential options for medically refractory patients (when all else fails).

Abstract

The most evidence exists for mixed anesthetic/steroid occipital nerve blocks (which are also useful in non-refractory patients), deep brain stimulation, sphenopalatine ganglion (SPG) blocks, SPG radiofrequency ablation, and SPG stimulation with the Autonomic Technologies, Inc (ATI) SPG Neurostimulator, the latter approved in the European Union and reimbursed in several countries.
© 2013 American Headache Society.

KEYWORDS:

LSD; cluster headache; neuromodulation; occipital nerve blocksphenopalatine ganglion stimulation; vagal nerve stimulation
posted by Dr Shapira at 1:35 PM 

Saturday, November 28, 2015

Can Neuromuscular Dentistry Treatment Prevent and Eliminate Migraines, Cluster Headaches and Chronic Daily Headaches

There is big money in the treatment of migraines.  Can Neuromuscular Dentistry prevent migraines better than drug therapy?

Learn more at www.IHateHeadaches.org   www.ThinkBetterLife.com

 According to the Tevapharm.com website Teva and Hepartes entered in an agreement to discover and develop novel, small-molecule CGRP Antagonists for treatment of migraine.  Hepartes may receive potential payments of $400 million.  This is excellent news because much of the current drug regimens have safety and effectiveness issues.

Is there a better alternative to CGRP Antagonists for migraine?  It is important to understand the underlying physiology of headache and migraine when considering this question.


Calcitonin gene-related peptide is a vaso-active neuropeptide released by branches of the Trigemino-vascular system of the Trigeminal Nerve.  CGRP and other neurotransmitters released at nerve synapses have been implicated in migraine headaches. 
Drug therapy for migraines are big business worldwide.  The question is there a better method of preventing and eliminating migraines available.
It is unlikely that funding to evaluate neuromuscular dentistry as migraine prevention will ever materialize.  This is in spite of the fact that it is well established that almost 100% of all headaches and migraines (including Trigeminal Autonomic cephalgias) are Trigeminally controlled.
The Trigeminal Nerve is often called the Dentist's nerve because it innervates the teeth (ie. dental pulp), the Periodontal Ligaments, the Jaw Muscles, the Jaw Joints, the anterior two thirds of the tongue, the tensor of the ear drum, the tensor of soft palate (opens and closes eustacian tubes).
The Trigemino-Cervical Complex descends cervically and connects to the sympathetic chain and is responsible for neck and occipital headaches.
The TrigeminoVascular System controls blood flow to the anterior two thirds of the meninges of the brai.  It is in this location that CGRP are released causing vaso dilation asociated with migraines.
The question is not can these drugs work but rather is it possible to prevent the release of the vasoactive neuropeptides by changing input to the trigeminal nervous system?
After accounting for amplification in the Reticular Activating System the Trigeminal Nervous System accounts for more that half of all input to the brain.
If we think of the brain as our central computer we can discuss the computer concept
GARBAGE IN- GARBAGE OUT  as a cause of all migraines and headaches.
Noxious input to the Trigeminal Nervous System causes release of neurotransmitters and vaso-active neuropeptides to the meninges of the brain  that are trigeminally innervated.
Can changing input correct migraine physiology.  The Sphenopalatine Ganglion (SPG) is the Largest Parasympathetic Ganglion of the head.  The SPG Block is extremely effective is stopping and preventing migraines and since it is generally done with lidocaine it is very safe.
Trigeminal fibers pass thru the Ganglion but do not have cell bodies there.  There are currently numerous implantable devices being studied that can change neural input to the Sphenopalatine Ganglion and treat Migraines, Cluster Headaches, Anxiety, Depression and many other disorders.  The block turns of the sympathetic overload of the fight or flight response.  In the parasympathetic mode we feel relaxation, safety, satiety, sexual,  loving, etc
This is proof of fact that changing neural input can treat, prevent and eliminate migraines and other headaches.
Neuromuscular Dentistry also has been shown to be very effective in treating patients with chronic headaches and migraines.  Unfortunately thousands of individual case studies do not carry the same evidence based medicine weight of double blind drug studies.  By its nature it is not possible to do double blind studies with neuromuscular Dentistry.......
There is a situation that clearly showed  the effectiveness of a Neuromuscular TMJ treatment program at Chicago HMO in the 1980's until 1993.
In the 1980's until 1993 I worked closely with Dr Mitchell Trubitt the Medical Director of Chicago HMO.  What started as a fight for insurance coverage for a single patient moved on to a test with six patients to see if Neuromuscular Dentistry could lead to cost savings for insurance compaines.  The initial test was six patients who were treated with neuromuscular orthotics for their TMJ and Headache problems.   All six patients had two surgical opinions stating TMJoint surgery was needed.  All six patients were treated without surgery.  The patients all reported being very happy with results that included relief of headaches and migraines.
The results were that we demonstrated estimated massive savings $250,000 on  just those six patients.  Because of the positive results of that test Chicago HMO began to cove 100% of the cost of Phase one Neuromuscular TMJ treatment .  These savings reflected hospitalization and surgery costs, surgical fees, anaesthesia and physical therapy.  Chicago HMO did not cover phase two treatment so all patients were fitted with appliances made on vitallium frameworks to prevent breakage.  Patients desiring orthodontics or crowns were not reimbursed by medical insurance.
Chicago HMO did not decide to cover  TMJ, disorders, in fact contract language specifically stated non-surgical treatment of TMJ problems were not covered.  In spite of that language Dr Trubitt authorized coverage due to cost savings.  Chicago HMO doctors who referred patients for non-surgical treatment actually were charged less for out of network referrals.  TMJ was given the same cost for referring physicians as Cancer and Heart Disease.
Patients not only experienced improvements in TMJ disorders but also reduction and elimination of headaches and migraines.  TMJ has been called "The Great Imposter" because so many diverse ymptoms are associated with it.  At the time Chicago HMO had no means of tracking drug savings nor did they consider costs of other related disorders.
When insurance coverage and out of pocket costs were taken out of the picture with a guarantee payment we were no longer in a pay per procedure mode but a global fee.  Trigger point injections, SPG Blocks and other procedures were used without additional costs leading to rapid patient improvement.
While there were no patient complaints during the program there were several complaints from oral surgeons objecting to a general dentist seeing patients for non-surgical treatment on patients they deemed surgery necessary.
In 1993 United Health Care bought out Chicago HMO (parent HMO America) and the program ended abruptly even though it had demonstrated significant savings over several years.
I met with the new medical director along with Dr Trubitt in an attempt to keep this very successful treatment and cost containment program going but was told that since United Health Care didn't pay for surgery they would save money treating TMJ non-surgically.
Four years after this experience The Shimshak article was  published that showed that patients carrying a TMJD diagnosis had a 200% increase in total medical expenses.  Shimshak stated "The majority of these differences were attributed to conditions that were not usually considered related to TMJ disorders. These utilization and cost differences extended, in varying degrees, over a wide range of diagnostic and healthcare provider categories."  (Pubmed abstract below)
One year later a follow-up study showed that the increased costs were actually 300% over patients not carrying TMJ diagnosis.  Shimshak stated "For some of the major diagnostic categories, such as nervous, respiratory, circulatory, and digestive, the inpatient and outpatient claims differences in utilization and costs were as large as 3 to 1. For only one diagnostic category, pregnancy and childbirth, were utilization and costs greater for non-TMJ subjects than TMJ patients. The psychiatric claims for TMJ patients exhibited differences that were at least twice as large as those for the non-TMJ subjects." (pubmed abstract below)

 1997 Apr;15(2):150-8.

Medical claims profiles of subjects with temporomandibular joint disorders.

Abstract

The primary goal of this study was to evaluate the claims profiles of subjects with TMJ disorders relative to a control group without the disorders and to provide a characterization of the type of healthcare services received and the associated costs of healthcare for patients with TMJ disorders. The administrative data base of a major medical insurer was used to compare the claims history of 1,819 patients diagnosed with TMJ disorders to matched controls. The analysis was based only on medical claims. The study found that total medical claim payments for the patients with TMJ disorders were double that of the subjects without TMJ disorders, and similarly, the utilization of institutional and professional care services was found to be approximately twice as high, though not uniformly distributed across all Major Diagnostic Categories, physician specialties or types of service. The level and nature of the differences in the quantity and costs of healthcare between subjects with and without TMJ disorders were unexpectedly large. The majority of these differences were attributed to conditions that were not usually considered related to TMJ disorders. These utilization and cost differences extended, in varying degrees, over a wide range of diagnostic and healthcare provider categories.

 1998 Jul;16(3):185-93.

Health care utilization by patients with temporomandibular joint disorders.

Abstract

The claims data base of a large New England managed care organization was used to compare the health care utilization patterns of patients with TMJ disorders to non-TMJ subjects. Inpatient, outpatient and psychiatric claims data were examined over a wide range of diagnostic categories. Age and sex adjusted results showed that, overall, patients with TMJ disorders were greater utilizers of health care services and had higher associated costs than non-TMJ subjects. For some of the major diagnostic categories, such as nervous, respiratory, circulatory, and digestive, the inpatient and outpatient claims differences in utilization and costs were as large as 3 to 1. For only one diagnostic category, pregnancy and childbirth, were utilization and costs greater for non-TMJ subjects than TMJ patients. The psychiatric claims for TMJ patients exhibited differences that were at least twice as large as those for the non-TMJ subjects.

Learn more at www.IHateHeadaches.org   www.ThinkBetterLife.com

posted by Dr Shapira at 9:11 AM 

CGRP Antagonists: Treatment of Migraine Can we prevent release of CGRP rather than treat with Antagonists

There is big money in the treatment of migraines.

 According to the Tevapharm.com website Teva and Hepartes entered in an agreement to discover and develop novel, small-molecule CGRP Antagonists for treatment of migraine.  Hepartes may receive potential payments of $400 million.  This is excellent news because much of the current drug regimens have safety and effectiveness issues.

Is there a better alternative to CGRP Antagonists for migrane.
Calcitonin gene-related peptide is a vaso-active neuropeptide released by branches of the Trigemino-vascular system of the Trigeminal Nerve.  CGRP and other neurotransmitters released at nerve synapses have been implicated in migraine headaches. 
Drug therapy for migraines are big business worldwide.  The question is there a better method of preventing and eliminating migraines available.
It is unlikely that funding to evaluate neuromuscular dentistry as migraine prevention will ever materialize.  This is in spite of the fact that it is well established that almost 100% of all headaches and migraines (including Trigeminal Autonomic cephalgias) are Trigeminally controlled.
The Trigeminal Nerve is often called the Dentist's nerve because it innervates the teeth (ie. dental pulp), the Periodontal Ligaments, the Jaw Muscles, the Jaw Joints, the anterior two thirds of the tongue, the tensor of the ear drum, the tensor of soft palate (opens and closes eustacian tubes).
The Trigemino-Cervical Complex descends cervically and connects to the sympathetic chain and is responsible for neck and occipital headaches.
The TrigeminoVascular System controls blood flow to the anterior two thirds of the meninges of the brai.  It is in this location that CGRP are released causing vaso dilation asociated with migraines.
The question is not can these drugs work but rather is it possible to prevent the release of the vasoactive neuropeptides by changing input to the trigeminal nervous system?
After accounting for amplification in the Reticular Activating System the Trigeminal Nervous System accounts for more that half of all input to the brain.
If we think of the brain as our central computer we can discuss the computer concept
GARBAGE IN- GARBAGE OUT  as a cause of all migraines and headaches.
Noxious input to the Trigeminal Nervous System causes release of neurotransmitters and vaso-active neuropeptides to the meninges of the brain  that are trigeminally innervated.
Can changing input correct migraine physiology.  The Sphenopalatine Ganglion (SPG) is the Largest Parasympathetic Ganglion of the head.  The SPG Block is extremely effective is stopping and preventing migraines and since it is generally done with lidocaine it is very safe.
Trigeminal fibers pass thru the Ganglion but do not have cell bodies there.  There are currently numerous implantable devices being studied that can change neural input to the Sphenopalatine Ganglion and treat Migraines, Cluster Headaches, Anxiety, Depression and many other disorders.  The block turns of the sympathetic overload of the fight or flight response.  In the parasympathetic mode we feel relaxation, safety, satiety, sexual,  loving, etc
This is proof of fact that changing neural input can treat, prevent and eliminate migraines and other headaches.
Neuromuscular Dentistry also has been shown to be very effective in treating patients with chronic headaches and migraines.  Unfortunately thousands of individual case studies do not carry the same evidence based medicine weight of double blind drug studies.  By its nature it is not possible to do double blind studies with neuromuscular Dentistry.......
There is a situation that clearly showed  the effectiveness of a Neuromuscular TMJ treatment program at Chicago HMO in the 1980's until 1993.
In the 1980's until 1993 I worked closely with Dr Mitchell Trubitt the Medical Director of Chicago HMO.  What started as a fight for insurance coverage for a single patient moved on to a test with six patients to see if Neuromuscular Dentistry could lead to cost savings for insurance compaines.  The initial test was six patients who were treated with neuromuscular orthotics for their TMJ and Headache problems.   All six patients had two surgical opinions stating TMJoint surgery was needed.  All six patients were treated without surgery.  The patients all reported being very happy with results that included relief of headaches and migraines.
The results were that we demonstrated estimated massive savings $250,000 on  just those six patients.  Because of the positive results of that test Chicago HMO began to cove 100% of the cost of Phase one Neuromuscular TMJ treatment .  These savings reflected hospitalization and surgery costs, surgical fees, anaesthesia and physical therapy.  Chicago HMO did not cover phase two treatment so all patients were fitted with appliances made on vitallium frameworks to prevent breakage.  Patients desiring orthodontics or crowns were not reimbursed by medical insurance.
Chicago HMO did not decide to cover  TMJ, disorders, in fact contract language specifically stated non-surgical treatment of TMJ problems were not covered.  In spite of that language Dr Trubitt authorized coverage due to cost savings.  Chicago HMO doctors who referred patients for non-surgical treatment actually were charged less for out of network referrals.  TMJ was given the same cost for referring physicians as Cancer and Heart Disease.
Patients not only experienced improvements in TMJ disorders but also reduction and elimination of headaches and migraines.  TMJ has been called "The Great Imposter" because so many diverse ymptoms are associated with it.  At the time Chicago HMO had no means of tracking drug savings nor did they consider costs of other related disorders.
When insurance coverage and out of pocket costs were taken out of the picture with a guarantee payment we were no longer in a pay per procedure mode but a global fee.  Trigger point injections, SPG Blocks and other procedures were used without additional costs leading to rapid patient improvement.
While there were no patient complaints during the program there were several complaints from oral surgeons objecting to a general dentist seeing patients for non-surgical treatment on patients they deemed surgery necessary.
In 1993 United Health Care bought out Chicago HMO (parent HMO America) and the program ended abruptly even though it had demonstrated significant savings over several years.
I met with the new medical director along with Dr Trubitt in an attempt to keep this very successful treatment and cost containment program going but was told that since United Health Care didn't pay for surgery they would save money treating TMJ non-surgically.
Four years after this experience The Shimshak article was  published that showed that patients carrying a TMJD diagnosis had a 200% increase in total medical expenses.  Shimshak stated "The majority of these differences were attributed to conditions that were not usually considered related to TMJ disorders. These utilization and cost differences extended, in varying degrees, over a wide range of diagnostic and healthcare provider categories."  (Pubmed abstract below)
One year later a follow-up study showed that the increased costs were actually 300% over patients not carrying TMJ diagnosis.  Shimshak stated "For some of the major diagnostic categories, such as nervous, respiratory, circulatory, and digestive, the inpatient and outpatient claims differences in utilization and costs were as large as 3 to 1. For only one diagnostic category, pregnancy and childbirth, were utilization and costs greater for non-TMJ subjects than TMJ patients. The psychiatric claims for TMJ patients exhibited differences that were at least twice as large as those for the non-TMJ subjects." (pubmed abstract below)

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 1997 Apr;15(2):150-8.

Medical claims profiles of subjects with temporomandibular joint disorders.

Abstract

The primary goal of this study was to evaluate the claims profiles of subjects with TMJ disorders relative to a control group without the disorders and to provide a characterization of the type of healthcare services received and the associated costs of healthcare for patients with TMJ disorders. The administrative data base of a major medical insurer was used to compare the claims history of 1,819 patients diagnosed with TMJ disorders to matched controls. The analysis was based only on medical claims. The study found that total medical claim payments for the patients with TMJ disorders were double that of the subjects without TMJ disorders, and similarly, the utilization of institutional and professional care services was found to be approximately twice as high, though not uniformly distributed across all Major Diagnostic Categories, physician specialties or types of service. The level and nature of the differences in the quantity and costs of healthcare between subjects with and without TMJ disorders were unexpectedly large. The majority of these differences were attributed to conditions that were not usually considered related to TMJ disorders. These utilization and cost differences extended, in varying degrees, over a wide range of diagnostic and healthcare provider categories.

 1998 Jul;16(3):185-93.

Health care utilization by patients with temporomandibular joint disorders.

Abstract

The claims data base of a large New England managed care organization was used to compare the health care utilization patterns of patients with TMJ disorders to non-TMJ subjects. Inpatient, outpatient and psychiatric claims data were examined over a wide range of diagnostic categories. Age and sex adjusted results showed that, overall, patients with TMJ disorders were greater utilizers of health care services and had higher associated costs than non-TMJ subjects. For some of the major diagnostic categories, such as nervous, respiratory, circulatory, and digestive, the inpatient and outpatient claims differences in utilization and costs were as large as 3 to 1. For only one diagnostic category, pregnancy and childbirth, were utilization and costs greater for non-TMJ subjects than TMJ patients. The psychiatric claims for TMJ patients exhibited differences that were at least twice as large as those for the non-TMJ subjects.

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posted by Dr Shapira at 1:44 PM

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