Sphenopalatiine Ganglion (SPG) Blocks: Most Comprehensive information on the Miracle Blocks featured in "MIRACLES ON PARK AVENUE"

The Sphenopalatine Ganglion Block (SPG) was featured in the book "Miracles on Park Avenue" 

SPG Blocks are considered a first line treatment for Headaches, Migraines, Trigeminal Autonomic Cephalgias and all types of headaches.

There are numerous posts on this sitee oon thee topic but the most comprehensive information based on peer reviewed journals, pubmed and many other sources is at the website http://www.sphenopalatineganglionblocks.com.

It has the top rated blog site on SPG Blocks also known as Pterygopalatine Ganglion Blocks, Nasal Ganglion Block, Sluder's Ganglion Block and Meckel's Ganglion  Block.

There is a reddit page on these blocks as well featuring compelling patient videos:  https://www.reddit.com/r/SPGBlocks/

Patients wiith TMJ Disorders and Headaches or Migraines will also find comprehensive information at http://www.ThinkBetterLiife.com

Dr Shapira currently has a paper accepted by Cranio Journal: The Journal of CranioMandibular and Sleep Practice that diiscusses utiliizing Sphenopalatine Ganglion Blocks and Neuromuscular Dentistry to finally propeerly address chronic headache pain that addresses both the Trigeminal Nervous Systtem, the TMJoints and the Autonomic Nervous System, ie the Sympathetiic and Parasympathetic nerves of the Sphenopalatine Ganglion.

Tension-Type Headache: AKA: Tension Headache, Muscle Contraction Headache, Psychomyogenic Headache, Stress Headache, Ordinary Headache, Essential Headache, Idiopathic Headache and Psychogenic Headache.

Tension-Type Headaches are extremely common affecting the majority of the public at some time during their lifetime.  It is commonly associated with Stress or more accurately how patients react to stressful periods. 

There is often considerable cross over between Tension-Type headaches and Medication Overuse Headache.

Tension-Type Headaches can be mild, moderate or severe to very severe and frequently patients refer to them as "my Migraine".  Migraine in Children are often misdiagnosed Tension Type Headaches associated with Myofascial Trigger Points.  Because Migraine pathogenesis is also not well understood there is a great deal of crossover diagnosis.  

This recent study; Eur J Pain. 2018 Feb;22(2):385-392. doi: 10.1002/ejp.1127. Epub 2017 Sep 26.  "CHILDREN WITH MIGRAINE:  PROVOCATION VIA PRESSURE TO MYOFASCIAL TRIGGER POINTS IN THE TRAPZIUS MUSCLE?"  is an excellent example of research which confuses or fails to clarify migraine and tension-type headaches.  The article is excellent looking at headaches from triggerpoints in the Trapezius muscle.  (abstract below at ent of post)

To understand Tension-Type Headaches I believe it  is extremely important to understand and know all of the referral patterns identifies in MPD or Myofascial Pain.  Any physician or dentist is compromised in their quality of care without this knowledge and is likely to  prescribe excessive or inappropriate medications.  

 I believe it is impossible to make a proper diagnosis in many patients until both  active and latent  trigger points have been identified and managed.  This is an essential step in the differential diagnosis and should be completed prior to medication prescriptions for triptans and other medications.

The website www.TriggerPoints.net is an excellent resource for patients and physicians dealing with Tension-Type Headaches and Migraines.  It is taken from the testbook "Myofascial Pain and Dysfunction: A Trigger Point Manual"  

I recommend that my patients buy this book to better understand their pain patterns, how they can prevent myofascial trigger points from forming and how they can improve the pain from these trigger points. 

The precise mechanisms of Tension-type headaches are not well understood.  There are many discussions that differentiate central and peripheral mechanisms.

The first known fact about Tension Headaches (and Migraines) is that they are primarily disorders of the Trigeminal Nervous System and the Trigeminal Vascular System.

There is also no question that the autonomic nervous system plays an enormous role especially the Sympathetic nervous system and the balance between the sympathetic and parasympathetic nervous system.  

Chronic Tension Type Headaches are a serious condition that can severely decrease quality of life and cause considerable disability.  

All patients with Tension-Type headaches of a severe or chronic nature should have the effects of the autonomic nervous system evaluated as part of the diagnostic work-up with a minimally invasive Diagnostic Sphenopalatine (Pterygopalatine) Ganglion Block.   https://www.sphenopalatineganglionblocks.com/managing-chronic-headaches-spg-block-sphenopalatine-ganglion-block/

The use of self-administered Sphenopalatine Ganglion (SPG) Blocks can often have almost immediate relief of even severe pain and sometimes spontaneous remission of the underlying headache with repeated use.

These blocks reset the autonomic nervous system and help with stress response (sympathetic) turning off "Fight or Flight Reflex" and turn on the Parasympathetic Reflex ie "Feed and Breed or Eat and Digest Reflex"

There is an incredible histor of pain relief including a 1930 scientific article by Hiram Byrd on "Sphenopalatine Phenomena" and a 1986 popular book "Miracles on Park Avenue" documenting the practice of Dr Milton Reder who exclusively utilized SPG Blocks to treat patients varied types of pain.

Dr Ho published an extensive review Sphenopalatine Ganglion Blocks and Modulation in a 2017 paper.  https://www.sphenopalatineganglionblocks.com/sphenopalatine-ganglion-block-radiofrequency-ablation-neurostimulation-systematic-review/

The concept of Neuromodulation is extremely important because it helps explain the amazing successes of neuromuscular dentistry in treating and eliminating headaches and migraines.  A basic concept in Neuromuscular Dentistry is utilizing the Myomonitor to relax muslces inervated by Trigeminal and facial nerves to find neuromuscular rest and occlusion which serves to give a healthy reset to the trigeminal nervous system as a patient functions and swallows.

The Myomonitor also acts as a Neuromodulation device of the Sphenopalatine Ganglion.  There is an incredible 50 year safety record of Sphenopalatine Stimulation with the Myomonitor when used by Neuromuscular Dentists.

Understanding how these processes work is important.  It is also important to hear patients stories.  This is a link to over 100 patient videos who have been treated with Neuromuscular Dentistry and SPG Blocks for Tension-Type Headaches, Migraines, TMJ disorders, Myofascial Pain and referred headaches and related sleep disorders.

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg/videos

PubMed Abstract

Eur J Pain. 2018 Feb;22(2):385-392. doi: 10.1002/ejp.1127. Epub 2017 Sep 26.

Children with migraine: Provocation of headache via pressure to myofascialtrigger points in the trapezius muscle? - A prospective controlled observational study.

Landgraf MN1,2, Biebl JT1,2, Langhagen T1,2, Hannibal I1,2, Eggert T2,3, Vill K1, Gerstl L1, Albers L4, von Kries R4, Straube A2,3, Heinen F1,2.

Author information

Abstract

BACKGROUND:

The objective was to evaluate a supposed clinical interdependency of myofascial trigger points and migraine in children. Such interdependency would support an interaction of spinal and trigeminal afferences in the trigemino-cervical complex as a contributing factor in migraine.

METHODS:

Children ≤18 years with the confirmed diagnosis of migraine were prospectively investigated. Comprehensive data on medical history, clinical neurological and psychological status were gathered. Trigger points in the trapezius muscle were identified by palpation and the threshold of pressure pain at these points was measured. Manual pressure was applied to the trigger points, and the occurrence and duration of induced headache were recorded. At a second consultation (4 weeks after the first), manual pressure with the detected pressure threshold was applied to non-trigger points within the same trapezius muscle (control). Headache and related parameters were again recorded and compared to the results of the first consultation.

RESULTS:

A total of 13 girls and 13 boys with migraine and a median age of 14.5 (Range 6.3-17.8) years took part in the study. Manual pressure to trigger points in the trapezius muscle led to lasting headache after termination of the manual pressure in 13 patients while no patient experienced headache when manual pressure was applied to non-trigger points at the control visit (p < 0.001). Headache was induced significantly more often in children ≥12 years and those with internalizing behavioural disorder.

CONCLUSION:

We found an association between trapezius muscle myofascial trigger points and migraine, which might underline the concept of the trigemino-cervical complex, especially in adolescents.

SIGNIFICANCE:

In children with migraine headache can often be induced by pressure to myofascial trigger points, but not by pressure to non-trigger points in the trapezius muscle. This supports the hypothesis of a trigemino-cervical-complex in the pathophysiology of migraine, which might have implications for innovative therapies in children with migraine.

© 2017 European Pain Federation - EFIC®.

PMID:

 

28952174

 

DOI:

 

10.1002/ejp.1127

Myofascial Pain Syndrome: MPS. A New Nomenclature for Myofascial Pain and Dysfunction: MPD

Myofascial Pain Syndrome: MPS

Relief of chronic Myofascial Pain and Dysfunction at www.ThinkBetterLife.com

Myofascial Pain Syndrome is a ewer term than Myofascial Pain and Dysfunction. It specifically takes Dysfunction out of the disorder which is a major mistake. Myofascial Pain is a disuse / misuse syndrome and is always a type of repetitive strain disorder.

TMJ Disorders, TMD,, Craniofacial Pain, Tension Headaches, Migraines,Cervicalgia and almost all chronic head and neck pain is directly related to Myofascial Pain and Dysfunction, MPD, MPS, Myofascial Pain Syndrome.  

Amazing Videos of Pain Relief from Migraines, TMJ, TMD, MPD, MPS, Fibromyalgia, Myofascial Pain Syndrome and Myofacial Pain and Dydfunction.

https://www.youtube.com/channel/UCk9Bfz6pklC7_UluWFHzLrg

Visit Dr Shapira's website to learn more and schedule an appointment.
www.ThinkBetterLife.com

 This type of change is designed to allow drug therapy instead of addressing underlying issues. It is part of an unfortunate swing in medicine to avoid cause and effect, corrrective actions, physical therapy, exercise, manual therapy and instead look at treatment with pharmaceuticals

90-95% of all pain is Myofascial Pain or pain coming from muscles and fascia. Dr Janet Travell wrote the book Myofascial Pain and Dysfunction: A Trigger Point Manual.

This youtube video is of a Fibromyalgia patient condemned by medicine to a life of constant pain. This diagnosis is faulty to say the least.
https://www.youtube.com/watch?v=A5xUFtuZe_Y
This patient has "Recovered" from fibromyalgia or never had fibromyalgia or the definition and signs and symptoms of fibromyalgia are a faulty system of diagnosis leading to faulty treatment.

Myofascial pain results from injury and chronic misuse of muscles. Repetiitive strain injury is the primary cause of SPG. Dysfunction or improper function is an essential issue in understanding these problems.

Myofascial pain is often mispronounced as Myofacial pain.

Fibromyalgia is a questionable diagnosis. How chronic MPD and Fibromyalgia are related is hotly contested. MPD patients recover and Fibromyalgia patients do not. Fibromyalgia can best be treated as systemic MPD but treating with the medical model leads to the medication model. This is a model that says recovery is not possible. I suggest treating all patients with a goal of complete remission initially. Treatment designed to promote healthy physiology is always better than treatment with medication to cover up symptoms.

Myofascial pain and Dysfunction (MPD) is a common, painful disorder that is responsible for many, if not the majority of pain clinic visits. MPD can affect any skeletal muscles in the body. Skeletal muscle accounts for approximately 50% of body weight, and there are approximately 400 muscles in the body. MP is responsible for many cases of chronic musculoskeletal pain and the diagnosis is commonly missed.

Mayo Clinic says about MPD "Myofascial pain syndrome is a chronic pain disorder. In myofascial pain syndrome, pressure on sensitive points in your muscles (trigger points) causes pain in seemingly unrelated parts of your body. This is called referred pain from muscle trigger points.."

Mayo clinic's description is actually and over-simplification. It is a result of distorted function that leads to formation of taut bands within the muscles. These are mediated through muscle spindles. The trigger points are areas of low EMG located in the taut band capable of causing pain referral to distant sites.

The term "Myofascial pain syndrome" leaves out the idea of Dysfunction. It is easy to move to medical management of functional problems when the dysfunction is discounted. MPD Typically occurs after a muscle has been contracted repetitively in an awkward manner. This can be caused by repetitive motions used in jobs or hobbies or by stress-related muscle tension. Tere is an enormous difference between healthy and unhealthy repetitive motions.

While nearly everyone has experienced muscle tension pain, the discomfort associated with myofascial pain and dysfunction syndrome persists or worsens over time if underlying issues are not corrected.. Treatment options for myofascial pain syndrome include physical therapy and trigger point injections. Pain medications and relaxation techniques also can help.

When patients also have TMJ disorders function becomes paramount.

MP can cause local or referred pain, tightness, tenderness, popping and clicking, stiffness and limitation of movement, autonomic phenomena, local twitch response (LTR) in the affected muscle, and muscle weakness without atrophy. Trigger points (TrPs), which cause referred pain in characteristic areas for specific muscles, restricted range of motion (ROM), and a visible or palpable LTR to local stimulation, are classic signs of MP. Over 70% of TrPs correspond to acupuncture points used to treat pain.[1]

An active TrP is an area that refers pain to a remote area in a defined pattern when local stimulation is applied. Satellite TrPs appear in response to a primary, active TrP and usually disappear after the primary TrP has been inactivated. Latent TrPs cause stiffness and limitation of ROM but no pain. Frequently, they are found in asymptomatic individuals.

Although MP and fibromyalgia have some overlapping features, they are separate entities; fibromyalgia is a widespread pain problem, not a regional condition caused by specific TrPs.

#myofascialpainSyndrome, #MPS,#MPS/MyofascialPainSyndrome , #IllinoisMPS, #ChicagoMPS, ##northshoreMPS, #HighlandParkMPS,
#ChicagoMyofascialPainSyndrome, #Illinoismyofascialpainsyndrome, #Northshoremyofascialpainsyndrome, #MayoclinincMPS, #Rehabilitationinstitutemyofascialpainsyndrome, #Universityofchicagomyofascialpainsyndrome

Migraine Treatment: Sphenopalatine Ganglion (SPG) Blocks are they a Magic Migraine Cure?

The Sphenopalatine Block has been called by some the Miracle Headache Cure after being popularized in the best selling book "Miracles on Park Avenue:  Techniques for Treating Arthritis and Other Chronic Pain" by Albert Benjamin Gerber.

While not a "MIRACLE CURE" it is definitely miraculous treatment for many patients.

The Sphenopalatine Ganglion (SPG)  (also called pterygopalatine ganglion, Meckel's Ganglion or the Nasal Ganglion) is the largest parasympathetic autonomic ganglion a group of nerve cells that is linked to the trigeminal nerve.  

The Trigeminal Nerve is the primary nerve involved in all migraines and other headaches.  

The Trigeminal Nerve is usually called the Dentist's Nerve because dentists are considered the experts in most peripheral aspects of the Trigeminal Nerve structures. The Trigeminal Nerve goes to the teeth, the gums (gingiva), the periodontal ligaments, the jaw joints (TMJ, TMJoint) or TemporoMandibular Joints, the lining of the sinuses, the jaw muscles, the tensor of the ear drum and the muscle that opens and closes the eustacian tube, the lacrimal glands (tear ducts) and is responsible for nasal congestion.

The Trigeminal Nerve is also the major control of blood flow to the anterior 2/3 of the meninges of the brain and central to almost 100% of headaches.  The Trigeminal Nerve accounts for over 50% of the total input to the brain after amplification in the Reticular Activating System.

TMJ Disorders are often called "The Great Imposter because the can mimic all types of headaches, migraines, sinus problems and ear problems.  The majority of chronic headache patients have similar myofascial pain at patients with TMJ.  Neuromuscular Dentistry can be the best treatment for many patients with chronic headaches.  Learn more at WWW.ThinkBetterLife.com.  

The SPG is located behind and lateral nose in the pterygopalatine fossa, and carries information about sensation, including pain, and also plays a role in autonomic functions, such as tearing and nasal congestion. 

The application of local anesthetics to the SPG and the trigeminal nerve can be extremely effective in eliminating and/or controlling all types of head pain including tension headaches, chronic daily headache, new persistent daily headache, Cluster headaches, and migraine staticus.  I

SPG blocks can be accomplished by nasal swaps placed intranasally, injections intra-orally or from externally (Most effective) and recently three devices have been FDA approved for performing SPG blocks.  These devices involve placing  anesthetic through a thin cannula that passes through the nasal cavity to insert numbing medication in and around the Sphenopalatine ganglion area where it passes through the mucosa ti the ganglion.  These devices are less invasive than the injection technique but also less effective.  The three devices are the Sphenocath®, the  Allevio®, and the Tx360®.

The nasal swabs have an enormous advantage as they can be self applied by patients on a daily basis and when done with continuos delivery are amazingly effective and very inexpensive.  

Different types of anesthetic solutions can be utilized with any of these techniques.

The nasal swabs are left in place for 20 minutes to 30 minutes if done in my office.  Patients with severe problems can actually leave them in longer and self apply a couple of times a day.   The most common side effects, regardless of how SPG blocks are given are all temporary, including numbness in the throat, low blood pressure, and infrequently nausea. 

References:

Maizels, M; Scott B; Cohen W; Chen W. Intranasal lidocaine for treatment of migraine: a randomized, double blind, controlled trial. JAMA 1996;27:319-21.

Piagkou, M; Demesticha, T; Troupis, T; Vlasis, K; Skandalakis, P; Makri, A; Mazarakis, A; Lappas, D;Piagkos, G; Johnson, EO. "The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice." Pain Pract. 2012;12(5):399-412.

Jenkin,s B; Tepper, SJ. "Neurostimulation for Primary Headache Disorders, Part 1: Pathophysiology and Anatomy, History of Neuromodulation in Headache Treatment, and Review of Peripheral Neuromodulation in Primary Headaches." Headache 2011;51:1254-1266.

Martelletti, P; Jensen, RH; Antal, A; Arcioni, R; Brighina, F’ de Tommaso, M; Franzini, A; Fontaine, D;Heiland, M; Jürgens, TP; Leone, M; Magis, D; Paemeleire, K; Palmisani, S; Paulus, W; May, A. "Neuromodulation of chronic headaches: position statement from the European Headache Federation." J Headache Pain 2013;14(1):86.

Khan, S; Schoenen, J; Ashina, M. "Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?" Cephalalgia 2014;34(5:382–391.

Schoenen, J; Jensen, RH; Lantéri-Minet, M; Láinez, MJ; Gaul, C; Goodman, AM; Caparso, A; May, A. "Stimulation of the sphenopalatine ganglion (SPG) for cluster headache treatment. Pathway CH-1: a randomized, sham-controlled study." Cephalalgia. 2013 Jul;33(10):816-30. 

SEVERE HEADACHES, MIGRAINES, FACIAL PAIN or TMD RELIEF : DR SHAPIRA CAN ARRANGE THREE DAY EVALUATION AND TREATMENT APPOINTMENT IN HIS OFFICE.

DON'T KNOW WHERE TO GO FOR PAIN RELIEF?

I frequently receive requests for referrals from across the country for patients with severe pain problems. While I usually try to find a Neuromuscular Dentist close to where you live some patients need more a very experienced practioner. I have been treating chronic pain for over 34 years since graduating dental school. While in school I was a pain patient and often experienced severe headaches and facial pain that even excessive doses of Fiorinal #3 did not touch.

Some patients who have been in severe pain want relief as soon as possible and I understand wanting to experience relief as soon as possible. A "JUMP START" appointment in my office is possible. My team can arrange a 3 day visit where we start with diagnostics on the first morning and deliver a neuromuscular orthotic in the afternoon. We can utilize SPG blocks, trigger point injections and other modalities to achieve rapid results.

I work with Dr Mark Freund who can arrange for an Atlas Axis evaluation and do Atlas-Orthogonol adjustments, if indicated.

Prior to making an appointment I require that patients submit an extensive history as well as fill out some forms.

I like patients to give me a complete history of their pain, what age it started, any history of trauma and/or surgical proceedures as well as a list of previous treatments, length of treatment and success of treatment. I will personally review this information before you are accepted as a patient. I see a maximum of two patients/month for "JUMP START" treatment due to time and scheduling constraints.

My team will arrange for a convenient hotel near the office. This is the same hotel I use for doctors and their teams when I give course. My patients fly in Sunday I meet with them at 8 AM and do an exam followed by a neuromuscular work-up. This takes approximately 4 hours. I then customize a Diagnostic Neuromuscular Orthotic in the afternoon.

I clearly want all patients to understand that there are no guarantees of success.

If we are successful in eliminating or relieving your pain and dysfunction significantly and you believe that you are substantially improved we will schedule ongoing visits as needed. The Diagnostic Orthotic is for initial treatment, healing and short-term stabilization. Long term stabilization is frequently required and can take many different forms. These alternatives will be discussed but may take many forms such as long-term orthotics, orthodontics, reconstruction, surgery. Each patient is unique so your treatment will be customized for you.

i am experiencing extremely severe headaches and also suffer from migraines but these severe headaches are totally different from a migraine

Angie: i was diagnosed with tmj maybe 20 years or so ago. i wear a "dentist fitted" night guard every night since the tmj diagnosis. i am experiencing extremely severe headaches and also suffer from migraines but these severe headaches are totally different from a migraine. i have even used migraine medications but these have yet to come close to helping with these severe headaches. could the tmj issue be the culprit here??? these headaches are hurting in the jaws, temples, across the forehead, terribly behind the eyes and in the back of my head and neck. an mri recently showed nothing abnormal in the head or neck? i have even tried muscle relaxers and prednisone, no relief. i do not have health insurance but am willing to sell my house or at least my car to get some help{jk}. but seriously, what could be causing these headaches? who would be the best doctor to see? i have been to a neurologist, a dentist, natural healers, you name it, i've been there. can you he lp me with this before i go crazy? thank you and i painfully look forward to your reply.


Dr Shapira Response:
Dear Angie

I do not think there is a "Best Doctor" You did not say if your night guard improved your condition. If it does than consider a 24 hour orthotic. A night guard treats a 24/7 problem just at night.

The normal MRI is good news. I know patient's often want to find a problem on an MRI but ruling out serious organic disease is good news.

I normally spend an hour or two reviewing history before initiating treatment treatment and utilize numerous modalities to address specific portions of the problem.

A diagnostic neuromuscular orthotic is an excellent point to start treatment as it can often give miraculous results. I see long distance patients in my office, Ideally 4 days in a row. Come to town Sunday night and I will see you as a first patient Monday for exam and consultation, diagnostic work-up and delivery of an orthotic in the afternoon. I will then see you for adjustments over the next three days. If you are interested in pursuing treatment at my office I would like a lot more information prior to your visit.

WHY IS NEUROMUSCULAR DENTISTRY SO SUCCESSFUL IN TREATING TMJ (TMD) DISORDERS AND HEADACHES. THE PRESENCE OF MYOFASCIAL PAIN IS THE LINK

TREATMENT OF TMD, TMJ DISORDERS, TENSION-TYPE HEADACHE AND MIGRAINE HAVE WIDE AREAS OF OVERLAP. THIS OVERLAP IS IN SYMPTOMS AND CAUSES BUT MYOFASCIAL TRIGGER POINTS ARE A MAJOR SOURCE OF PAIN.

NEUROMUSCULAR DENTISTRY IS VERY SUCCESSFUL AT TREATING TMJ, TMD AND MYOFASCIAL PAIN DISORDERS OF THE HEAD AND NECK. PATIENTS WHO DO NOT WANT LONG TERM DRUG THERAPY SHOULD CONSIDER THE NEUROMUSCULAR DENTISTRY APPROACH TO IMPROVING THE HEALTH OF THE MASTICATORY SYSTEM, RELIEVING CHRONIC MUSCLE PAIN AND MYOFASCIAL TRIGGER POINTS AND PREVENTING CENTRAL SENSITIZATION.

THE LITERATURE STRONGLY SUPPORTS THE ROLE OF MUSCLES IN CHRONIC PAIN. A DIAGNOSTIC NEUROMUSCULAR ORTHOTIC IS AN IDEAL FIRST STEP FOR LONG TERM TREATMENT OF TMJ (TMD) DISORDERS AND HEADACHES. NEUROMUSCULAR DENTISTS FREQUENTLY WORK IN CONJUNCTION WITH PHYSICAL THERAPISTS, CHIROPRACTERS, OSTEOPATHS AND MASSAGE THERAPISTS.

IMPROVING THE QULITY OF LIFE OF PATIENTS ARISING FROM MUSCULAR DISORDERS AND IDEALIZING HOMEOSTASIS ARE BASIC TO NEUROMUSCULAR DENTAL TREATMENT.

There are 576 scientific articles that come up on a PubMed search using key terms of Myofascial Pain and TMJ. 221 PubMed articles come up searching Myofascial pain and Headache, and 61 articles when searching Myofascial Pain and Migraine. There are another 80 articles that come up searching Myofascial Pain and Tension-type Headaches.

Myofascial Pain is a constant in these searches. Myofascial pain results from repetitive overuse syndromes and is commonly considered a major component of TMD.
Neuromuscular Dentistry is directed toward treating myofascial pain, muscle spasm and other muscular disorders of the masticatory system.

An article "Temporomandibular Disorders are Differentially Associated With Headache Diagnoses: A Controlled Study." published in Feb 2011 Clinical Journal of Pain (abstract below) found that " TMD, TMD subtypes, and TMD severity are independently associated with specific headache syndromes and with headache frequency. This differential association suggests that the presence of central facilitation of nociceptive inputs may be of importance, as positive association was observed only when muscular TMD pain was involved."

Central facillitation is central to many theories on why some patients get chronic headaches and migraines. Another article, "Referred pain from myofascial trigger points in head and neck-shoulder muscles reproduces head pain features in children with chronic tension type headache." in the Feb 2011 Journal of Headache Pain (abstract below) confirms that tension type headaches in children are associated with myofascial pain.

The article states that "TrPs (myofascial trigger points) were identified with palpation and considered active when local and referred pains reproduce headache pain attacks." and that "The total number of TrPs was significantly greater in children with CTTH (chronic tension type headache) as compared to healthy children"

More significantly it stated "Active TrPs were only present in children with CTTH (P < 0.001). Within children with CTTH, a significant positive association between the number of active TrPs and headache duration (r (s) = 0.315; P = 0.026) was observed: the greater the number of active TrPs, the longer the duration of headache attack.

THIS MEANS THAT TRIGGER POINTS CAUSE TENSION TYPE HEADACHES IN CHILDREN, THE MORE TRIGGER POINTS THAT WERE PRESENT THE LONGER THE HEADACHES LASTED.

The study found a similar association with neck pain and trigger points " Our results showed that the local and referred pains elicited from active TrPs in head, neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active TrPs in CTTH in children."

Another 2011 article "The relationship of temporomandibular disorders with headaches: a retrospective analysis." (abstract below)found that "The TMJ and associated orofacial structures should be considered as possible triggering or perpetuating factors for headaches, especially tension-type. There might be a significant connection between TMD and headache. However, most medical and dental practitioners are unaware of this relationship. Therefore, a careful evaluation of the TMJ and associated orofacial structures is required for a correct interpretation of the craniofacial pain in headache patients, and these patients should be managed with a multidisciplinary approach."

THIS MEANS THAT HEADACHES, ESPECIALLY TENSION-TYPE HEADACHES ARE FREQUENTLY CAUSED ASSOCIATED WITH TMD OR TMJ DISORDERS.

ANOTHER STUDY FROM DECEMBER 2010 JOURNAL PAIN "Influence of headache frequency on clinical signs and symptoms of TMD in subjects with temple headache and TMD pain." SHOWED CORRELATIONS OF HEADACHE FREQUENCY TO TMD.

THEY CONCLUDED THAT "these findings suggest that these headaches may be TMD related, as well as suggesting a possible role for peripheral and central sensitization in TMD patients. Subjects with painful temporomandibular disorders (TMD) showed significant trends for increased signs and symptoms of TMD associated with increased frequency of concurrent temple headaches."

THIS MEANS THAT THE CENTRAL SENSITIZATION FOUND IN HEADACHES, MIGRAINES AND FIBROMYALGIA ARE POSSIBLY DUE TO TMD.

THE ARTICLE "Pure tension-type headache versus tension-type headache in the migraineur." FROM Curr Pain Headache Rep. 2010 Dec;14(6):465-9. STATES THAT IT CAN BE DIFFICULT TO DIFFERENTIATE MIGRAINE, TENSION TYPE HEADACHES AND SYMPTOMS OF TMD ESPECIALLY IN THE CASE OF CHRONIC PAIN.








Clin J Pain. 2011 Feb 28. [Epub ahead of print]
Temporomandibular Disorders are Differentially Associated With Headache Diagnoses: A Controlled Study.

Gonçalves DA, Camparis CM, Speciali JG, Franco AL, Castanharo SM, Bigal ME.

*Department of Dental Materials and Prosthodontics, Araraquara Dental School, Sao Paulo State University †Department of Neurology, School of Medicine at Ribeirao Preto, University of Sao Paulo Ribeirao Preto, São Paulo, Brazil ‡Department of Neurology, Albert Einstein College of Medicine, Bronx, NY §Merck Research Laboratories, West Point, PA, USA.
Abstract

OBJECTIVES: Temporomandibular disorders (TMDs) are considered to be comorbid with headaches. Earlier population studies have suggested that TMD may also be a risk factor for migraine progression. If that is true, TMD should be associated with specific headache syndromes (eg, migraine and chronic migraine), but not with headaches overall. Accordingly, our aim was to explore the relationship between TMD subtypes and severity with primary headaches in a controlled clinical study.

METHODS: The sample consisted of 300 individuals. TMDs were assessed using the Research Diagnostic Criteria for TMD, and primary headache was classified according to International Classification for Headache Disorders-2. Univariate and multivariate models assessed headache diagnoses and frequency as a function of the parameters of TMD.

RESULTS: Relative to those without TMD, individuals with myofascial TMD were significantly more likely to have chronic daily headaches (CDHs) [relative risk (RR)=7.8; 95% confidence interval (CI), 3.1-19.6], migraine (RR=4.4; 95% CI, 1.7-11.7), and episodic tension-type headache (RR=4.4; 95% CI, 1.5-12.6). Grade of TMD pain was associated with increased odds of CDH (P<0.0001), migraine (P<0.0001), and episodic tension-type headache (P<0.05). TMD severity was also associated with headache frequency. In multivariate analyses, TMD was associated with migraine and CDH (P=0.001). Painful TMD (P=0.0034) and grade of TMD pain (P<0.001) were associated with headache frequency.

DISCUSSION: TMD, TMD subtypes, and TMD severity are independently associated with specific headache syndromes and with headache frequency. This differential association suggests that the presence of central facilitation of nociceptive inputs may be of importance, as positive association was observed only when muscular TMD pain was involved.

PMID: 21368664 [PubMed - as supplied by publisher]

J Headache Pain. 2011 Feb 27. [Epub ahead of print]
Referred pain from myofascial trigger points in head and neck-shoulder muscles reproduces head pain features in children with chronic tension type headache.

Fernández-de-Las-Peñas C, Fernández-Mayoralas DM, Ortega-Santiago R, Ambite-Quesada S, Palacios-Ceña D, Pareja JA.

Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain, cesar.fernandez@urjc.es.
Abstract

Our aim was to describe the referred pain pattern and areas from trigger points (TrPs) in head, neck, and shoulder muscles in children with chronic tension type headache (CTTH). Fifty children (14 boys, 36 girls, mean age: 8 ± 2) with CTTH and 50 age- and sex- matched children participated. Bilateral temporalis, masseter, superior oblique, upper trapezius, sternocleidomastoid, suboccipital, and levator scapula muscles were examined for TrPs by an assessor blinded to the children's condition. TrPs were identified with palpation and considered active when local and referred pains reproduce headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured. The total number of TrPs was significantly greater in children with CTTH as compared to healthy children (P < 0.001). Active TrPs were only present in children with CTTH (P < 0.001). Within children with CTTH, a significant positive association between the number of active TrPs and headache duration (r (s) = 0.315; P = 0.026) was observed: the greater the number of active TrPs, the longer the duration of headache attack. Significant differences in referred pain areas between groups (P < 0.001) and muscles (P < 0.001) were found: the referred pain areas were larger in CTTH children (P < 0.001), and the referred pain area elicited by suboccipital TrPs was larger than the referred pain from the remaining TrPs (P < 0.001). Significant positive correlations between some headache clinical parameters and the size of the referred pain area were found. Our results showed that the local and referred pains elicited from active TrPs in head, neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active TrPs in CTTH in children.

PMID: 21359873 [PubMed - as supplied by publisher]

Agri. 2011 Jan;23(1):13-7.
The relationship of temporomandibular disorders with headaches: a retrospective analysis.

Cakır Özkan N, Ozkan F.

Department of Oral and Maxillofacial Surgery, Gaziosmanpaşa University Faculty of Medicine, Tokat, Turkey.
Abstract

Objectives: The objective of this study was to retrospectively analyze the incidence of the concurrent existence of temporomandibular disorders (TMD) and headaches. Methods: Forty patients (36 female, 4 male, mean age: 29.9±9.6 years) clinically diagnosed with TMD were screened. Patient records were analyzed regarding: range of mouth opening, temporomandibular joint (TMJ) noises, pain on palpation of the TMJ and masticatory muscles and neck and upper back muscles, and magnetic resonance imaging of the TMJ. Results: According to patient records, a total of 40 (66.6%) patients were diagnosed with TMD among 60 patients with headache. Thirty-two (53%) patients had TMJ internal derangement (ID), 8 (13%) patients had only myofascial pain dysfunction (MPD) and 25 (41.6%) patients had concurrent TMJ ID/MPD. There were statistically significant relationships between the number of tender masseter muscles and MPD patients (p=0.04) and between the number of tender medial pterygoid muscles and patients with reducing disc displacement (RDD) (p=0.03). Conclusion: The TMJ and associated orofacial structures should be considered as possible triggering or perpetuating factors for headaches, especially tension-type. There might be a significant connection between TMD and headache. However, most medical and dental practitioners are unaware of this relationship. Therefore, a careful evaluation of the TMJ and associated orofacial structures is required for a correct interpretation of the craniofacial pain in headache patients, and these patients should be managed with a multidisciplinary approach.

PMID: 21341147 [PubMed - in process]

Pain. 2010 Dec 31. [Epub ahead of print]
Influence of headache frequency on clinical signs and symptoms of TMD in subjects with temple headache and TMD pain.

Anderson GC, John MT, Ohrbach R, Nixdorf DR, Schiffman EL, Truelove ES, List T.

University of Minnesota School of Dentistry, Department of Developmental and Surgical Sciences, Minneapolis, MN, USA.
Abstract

The relationship of the frequency of temple headache to signs and symptoms of temporomandibular joint (TMJ) disorders (TMD) was investigated in a subset of a larger convenience sample of community TMD cases. The study sample included 86 painful TMD, nonheadache subjects; 309 painful TMD subjects with varied frequency of temple headaches; and 149 subjects without painful TMD or headache for descriptive comparison. Painful TMD included Research Diagnostic Criteria for Temporomandibular Disorders diagnoses of myofascial pain, TMJ arthralgia, and TMJ osteoarthritis. Mild to moderate-intensity temple headaches were classified by frequency using criteria based on the International Classification of Headache Disorder, 2nd edition, classification of tension-type headache. Outcomes included TMD signs and symptoms (pain duration, pain intensity, number of painful masticatory sites on palpation, mandibular range of motion), pressure pain thresholds, and temple headache resulting from masticatory provocation tests. Trend analyses across the painful TMD groups showed a substantial trend for aggravation of all of the TMD signs and symptoms associated with increased frequency of the temple headaches. In addition, increased headache frequency showed significant trends associated with reduced PPTs and reported temple headache with masticatory provocation tests. In conclusion, these findings suggest that these headaches may be TMD related, as well as suggesting a possible role for peripheral and central sensitization in TMD patients. Subjects with painful temporomandibular disorders (TMD) showed significant trends for increased signs and symptoms of TMD associated with increased frequency of concurrent temple headaches.
Copyright © 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

PMID: 21196079 [PubMed - as supplied by publisher]

Curr Pain Headache Rep. 2010 Dec;14(6):465-9.
Pure tension-type headache versus tension-type headache in the migraineur.

Blumenfeld A, Schim J, Brower J.

The Headache Center of Southern California, 320 Santa Fe Drive, Encinitas, CA 92024, USA. blumenfeld@neurocenter.com
Abstract

Primary headache disorders include tension-type headache and migraine. These headache types can be differentiated based on strict clinical definitions that depend on the patient's signs and symptoms. However, some of the clinical features can overlap, and in addition, the same comorbid conditions can occur in both headache types. Distinction between these headache types on occasion can be difficult due to comorbid conditions such as temporomandibular joint disorders and myofascial pain with forward head posturing, which may be present in both headache disorders, and thus result in similar features in both conditions. Furthermore, chronification, particularly of migraine, leads to a decrease in the associated symptoms of migraine, such as nausea, photophobia, and phonophobia, so that these headaches more closely resemble tension-type headache. Finally, in some patients, both tension-type headache and migraine may occur at different times.

PMID: 20878271 [PubMed - indexed for MEDLINE]

Bent Face Syndrome, THJ Disorders and Chronic Tension Headache and Migraines

TMJ disorders and headaches are closely related. There are distinct differences in underlying structural differences in patients who experience Tension-Type Headaches and Migraine.

The pain can be primarily related to cervical and cranial musculature but can also be secondary to postural distortions that effect the central nervous system.

Bent Face Syndrome is caused by orthopedic displacement of cranial bones or Cranial Orthopedic Distortions. Other patients have Dental Distortions but the Cranial bones are correctly positioned. Most frequently patients have simultaneous cranial and dental distortions.

Symptoms can be headaches, ear aches, ear pressure, retro-orbital eye pain or pressure, ear stuffiness or mild, moderate, or severe and immobolizing headaches or migraines.

Correction of bites may not correct the underlying cranial bone distortion. As I write this I am in the middle of a course with Dr Bob Walker (founder of Chirodontics) who has developed simple methods to diagnose and treat both the cranial and dental problems. Inn addition to reductions in pain there is also major improvements in facial esthetics.

These methods can lead to rapid correction of these problems and improve final positioning. I first saw Bob present this information at the ICCMO meeting in October. What he accomplished was "impossible". After spending a full day with him I now know it is not only possible but relatively quick and easy. He also helps point out which patients are most likely to be very difficult to treat.

British Study Show That Botox Offers 'little help' for migraines.

The BBC news reproted that experts say there is "limited evidence" for using botox to treat migraine.


Botox has been licensed in the UK and US as a preventative treatment for chronic cases.

The BBC reprted that "But a review of evidence by the Drug and Therapeutics Bulletin said it could not "see a place" for giving botox to migraine sufferers."

New Article ties Joint hypermobility syndrome to migraines. This has long been known to be a factor in TMJ disorders and associated headaches.

Studies have shown that hypermobility syndrome is associated with chronic headache disorders. This new study shows that 75% of study group with the syndrome had migraines compared to only 43% of controls.

Patients with Chronic Daily Headaches, Migraines, Tension-type headaches, myofascial pain and associated headaches, atypical migaine, classic migraine almost always are headaches related to the masticatory system, the trigeminal nerve and TMJ disorders(TMD). These problems are often best addressed by the use of a diagnostic neuromuscular orthotic that has been shown in various studies to give some improvement in close to 100% of patients. Almost all studies of orthotics (of all types) show better then 50 % of patients experiencing considrable improvement and in my experience neuromuscular orthotics are far superior to the typical orthotic. Patients with migraines and/or muscular headaches would be well advised to consider temporomandibular disorders as part of a differential diagnosis.

Unfortunately for most patients with migraines neurologists will usually begin with drug trials in spite of side effects and statistically lower response rates. Patients usually turn to neuromuscular dentistry after years of suffering. often the suffering was needless. Most physicians are not well informed about the field of neuromuscular dentistry.

Recent articles from the International Acadery of Dental Research have done an enormous disservice to patients by promoting the psychological and biosocial aspects of chronic pain strongly supporting the notion that drug therapy should precede occlusal therapy. This is a biased view that is particularly destructive to patients labeling their pain as a psychosocial disorder to be treated by drugs ignoring the underlying neuromuscular systems and trigemino-vascular connections that are best treated by neuromuscular orthotics.

I have listed a few of the 211 PubMed.gov abstracts below that are revealed by searching PubMed with these search terms; joint hypermobility , tmj

The study showed that "The adjusted odds ratio for the prevalence of migraine was 3.19 in JHS patients" and that " The rate ratios for migraine frequency and headache-related disability were 1.67 for JHS patients"

The authors stated "Our study suggests that JHS is a clinical disorder strongly associated with an increased prevalence, frequency, and disability of migraine in females."

Hypermobility symptom is a major risk factor for TMJ (TMD) disorders


Cephalalgia. 2011 Feb 2. [Epub ahead of print]
Joint hypermobility syndrome: A common clinical disorder associated with migraine in women.
Bendik EM, Tinkle BT, Al-Shuik E, Levin L, Martin A, Thaler R, Atzinger CL, Rueger J, Martin VT.

University of Cincinnati College of Medicine, USA.
Abstract
Preliminary studies suggested that headache disorders are more common in patients with joint hypermobility syndrome (JHS). The objectives of this study were to determine if the prevalence, frequency, and disability of migraine differ between female patients with JHS and a control population. Twenty-eight patients with JHS and 232 controls participated in the case-cohort study. Participants underwent a structured verbal interview and were assigned a diagnosis of migraine based on criteria of the International Classification of Headache Disorders, 2nd Edition. The primary outcome measures were the prevalence, frequency, and headache-related disability of migraine. Logistic regression was used for the prevalence analysis and Poisson regression for the frequency and disability analyses. Results indicated that the prevalence of migraine was 75% in JHS patients and 43% in controls. The adjusted odds ratio for the prevalence of migraine was 3.19 (95% CI 1.24, 8.21] in JHS patients. The rate ratios for migraine frequency and headache-related disability were 1.67 (95% CI 1.01, 2.76) and 2.99 (95% CI 1.66, 5.38), respectively, for JHS patients. Our study suggests that JHS is a clinical disorder strongly associated with an increased prevalence, frequency, and disability of migraine in females.

PMID: 21278238 [PubMed - as supplied by publisher]

Acta Odontol Scand. 2010 Sep;68(5):289-99.
Risk factors associated with incidence and persistence of signs and symptoms of temporomandibular disorders.
Marklund S, Wänman A.

Department of Odontology, Umeå University, Sweden. susanna.marklund@odont.umu.se
Abstract
OBJECTIVE: To analyze whether gender, self-reported bruxism, and variations in dental occlusion predicted incidence and persistence of temporomandibular disorder (TMD) during a 2-year period.

MATERIAL AND METHODS: The study population comprised 280 dental students at Umeå University in Sweden. The study design was that of a case-control study within a 2-year prospective cohort. The investigation comprised a questionnaire and a clinical examination at enrolment and at 12 and 24 months. Cases (incidence) and controls (no incidence) were identified among those without signs and symptoms of TMD at the start of the study. Cases with 2-year persistence of signs and symptoms of TMD were those with such signs and symptoms at all three examinations. Clinical registrations of baseline variables were used as independent variables. Odds ratio estimates and 95% confidence intervals of the relative risks of being a case or control in relation to baseline registrations were calculated using logistic regression analyses.

RESULTS: The analyses revealed that self-reported bruxism and crossbite, respectively increased the risk of the 2-year cumulative incidence and duration of temporomandibular joint (TMJ) signs or symptoms. Female gender was related to an increased risk of developing and maintaining myofascial pain. Signs of mandibular instability increased the risk of maintained TMD signs and symptoms during the observation period.

CONCLUSION: This 2-year prospective observational study indicated that self-reported bruxism and variations in dental occlusion were linked to the incidence and persistence of TMJ signs and symptoms to a higher extent than to myofascial pain.

PMID: 20528485 [PubMed - indexed for MEDLINE]

J Orofac Pain. 2009 Fall;23(4):303-11.
Evaluation of the Research Diagnostic Criteria for Temporomandibular Disorders for the recognition of an anterior disc displacement with reduction.
Naeije M, Kalaykova S, Visscher CM, Lobbezoo F.

Department of Oral Kinesiology, Academic Centre for Dentistry Amsterdam (ACTA), Research Institute MOVE, University of Amsterdam and VU University Amsterdam, Amsterdam, The Netherlands. m.naeije@acta.nl
Comment in:

J Orofac Pain. 2009 Fall;23(4):312-5; author reply 323-4.
J Orofac Pain. 2009 Fall;23(4):320-2; author reply 323-4.
J Orofac Pain. 2009 Fall;23(4):316-9; author reply 323-4.
Abstract
The aim of this Focus Article is to review critically the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) for the recognition of an anterior disc displacement with reduction (ADDR) in the temporomandibular joint (TMJ). This evaluation is based upon the experience gained through the careful analysis of mandibular movement recordings of hundreds of patients and controls with or without an ADDR. Clinically, it is a challenge to discriminate between the two most prevalent internal derangements of the TMJ: ADDR and symptomatic hypermobility. It is due to the very nature of these derangements that they both show clicking on opening and closing (reciprocal clicking), making reciprocal clicking not a distinguishing feature between these disorders. However, there is a difference in timing of their opening and closing clicks. Unfortunately, it is not feasible to use this difference in timing clinically to distinguish between the two internal derangements, because it is the amount of mouth opening at the time of the clicking which is clinically noted, not the condylar translation. Two other criteria proposed by the RDC/TMD for the recognition of an ADDR are the 5-mm difference in mouth opening at the time of the opening and closing clicks, and the detection of joint sounds on protrusion or laterotrusion in case of non?reciprocal clicking. These, however, run the risk of false-positive or negative results and therefore have no great diagnostic value. Instead, it is recommended that the elimination of clicking on protrusive opening and closing be examined in order to distinguish ADDRs from symptomatic hypermobility.

PMID: 19888478 [PubMed - indexed for MEDLINE]

Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 Jun;107(6):e54-7.
Joint hypermobility and disk displacement confirmed by magnetic resonance imaging: a study of women with temporomandibular disorders.
Sáez-Yuguero Mdel R, Linares-Tovar E, Calvo-Guirado JL, Bermejo-Fenoll A, Rodríguez-Lozano FJ.

Faculty of Medicine, University of Murcia, Murcia, Spain. mrosario@um.es
Abstract
OBJECTIVE: The objective of this study was to test whether or not there is an association between generalized joint hypermobility (measured using the Beighton score) and temporomandibular joint disk displacement in women who had sought medical attention for temporomandibular disorders (TMD).

STUDY DESIGN: We studied 66 women who were attending the clinic for TMD. The patients were examined for joint hypermobility, and Beighton scores were calculated. When it was suspected that a patient suffered arthropathic complaints, magnetic resonance imaging of both temporomandibular joints was performed with the mouth closed and at maximal opening. The Pearson chi-squared test was used to test for an association between generalized joint hypermobility and disk displacement.

RESULTS: We were unable to confirm the existence of an association between generalized joint hypermobility and temporomandibular joint disk displacement in women (chi(2) = 1.523; P = .02).

CONCLUSION: Generalized joint hypermobility may be a factor related to TMD, but we did not find an association between generalized joint hypermobility and anterior disk displacement in women.

PMID: 19464645 [PubMed - indexed for MEDLINE]

Eur J Oral Sci. 2008 Dec;116(6):525-30.
Association between generalized joint hypermobility and signs and diagnoses of temporomandibular disorders.
Hirsch C, John MT, Stang A.

Department of Pediatric Dentistry, School of Dentistry, University of Leipzig, Leipzig, Germany. christian.hirsch@medizin.uni-leipzig.de
Comment in:

J Evid Based Dent Pract. 2010 Jun;10(2):91-2.
Abstract
The aim of this study was to analyze whether generalized joint hypermobility (GJH) is a risk factor for temporomandibular disorders (TMD). We examined 895 subjects (20-60 yr of age) in a population-based cross-sectional sample in Germany for GJH according to the Beighton classification and for TMD according to the Research Diagnostic Criteria for TMD (RDC/TMD). After controlling for the effects of age, gender, and general joint diseases using multiple logistic regression analyses, hypermobile subjects (with four or more hypermobile joints on the 0-9 scale) had a higher risk for reproducible reciprocal clicking as an indicator for disk displacement with reduction (Odds Ratio (OR) = 1.68) compared with those subjects without hypermobile joints. Concurrently, subjects with four or more hypermobile joints had a lower risk for limited mouth opening (< 35 mm; OR = 0.26). The associations between GJH and reproducible reciprocal clicking or limited mouth opening were statistically significant in a trend test. No association was observed between hypermobility and myalgia/arthralgia (RDC/TMD Group I/IIIa). In conclusion, GJH was found to be associated with non-painful subtypes of TMD.

PMID: 19049522 [PubMed - indexed for MEDLINE]

Publication Types, MeSH Terms



Dentomaxillofac Radiol. 2010 Dec;39(8):494-500.
Evaluation of the lateral pterygoid muscle using magnetic resonance imaging.
D'Ippolito SM, Borri Wolosker AM, D'Ippolito G, Herbert de Souza B, Fenyo-Pereira M.

Rua Prof Filadelfo Azevedo, 617, apt. 61, 04508-011, São Paulo, SP, Brazil. silvia.dippolito@uol.com.br
Abstract
OBJECTIVES: The aims of this study were to evaluate the visibility of the lateral pterygoid muscle (LPM) in temporomandibular joint (TMJ) images obtained by MRI, using different projections and to compare image findings with clinical symptoms of patients with and without temporomandibular disorders (TMD).

METHODS: In this study, LPM images of 50 participants with and without TMDs were investigated by MRI. The images of the LPM in different projections of 100 TMJs from 35 participants (70 TMJs) with and 15 participants (30 TMJs) without clinical signs and symptoms of TMD were visible and analysed.

RESULTS: The oblique sagittal and axial images of the TMJ clearly showed the LPM. Hypertrophy (1.45%), atrophy (2.85%) and contracture (2.85%) were the abnormalities found in the LPM. TMD signs, such as hypermobility (11.4%), hypomobility (12.9%) and disc displacement (20.0%), could be seen in TMJ images. Related clinical symptoms, such as pain (71.4%), articular sounds (30.4%), bruxism (25.7%) and headache (22.9%), were observed.

CONCLUSIONS: Patients with TMD can present with alterations in the LPM thickness. Patients without TMD also showed alterations, such as atrophy and contracture, in TMJ images. Recognition of alterations in the LPM will improve our understanding of clinical symptoms and pathophysiology of TMD, and may lead to a more specific diagnosis of these disorders.

PMID: 21062943 [PubMed - indexed for MEDLINE

Why you want to find the most experienced Neuromuscular Dentist to Treat TMJ, TMD, Headaches and Migraines.

Neuromuscular Dentistry can give incredible relief of headaches, TMJ symptoms migraines and numerous other chronic pain disorders. It is important to chose your Neuromuscular Dentist wisely.

The International College of CranioMandibular Disorders is dedicated to the field of Neuromuscular Dentistry. It was founded by Dr Barney Jankelson the father of Neuromuscular Dentistry and all the great teachers and researchers in the field have supported ICCMO. The ICCMO website is http://www.iccmo.org/

I strongly suggest that you search for an experienced neuromuscular dentist but also a dentist who is well versed in other areas of pain management and treatment. I am a Diplomate of the American Academy of Pain Management, and a member of American Academy of Craniofacial pain, The American Equilibration Society and well as a Fellow of ICCMO. I utilize Neuromuscular Dentistry whenever I treat chronic pain but I have learned many valuable techniques from my colleagues in these other groups as well. I know that when I attend the AES meeting later this month many of the top neuromuscular dentists will be in attendance. The AES is primarily comprised of Centric Relation dentists but they tops in their field as well.
While I firmly believe the Neuromuscular approach is ideal many of these practioners have excellent results as well. It is incredibly important that your dentist is always in search of continuing knowledge. Excellence demands that practitioners are constantly learning as well as evaluating and reevaluating their techniques and beliefs.

The treatment of Myofascial pain, trigger point injections, spray and stretch, spenopalatine ganglion blocks, prolotherapy are just a few of the effective treatments that are used in conjuction with Neuromuscular Dentistry to improve patients lives. Over the last 35 years of continuing education after graduating dental school I have learned many of these procedures from excellent practitioners who are not neuromuscular dentists. Many of my teachers were physicians, osteopaths, massage therapists, accupuncturists, psychologists, ENT's, Chiropracters and othe diverse mainstream and alternative practitioners.

The American Equilibration Society asked me to contribute an article on Neuromuscular Dentistry for publication. They have graciously allowed it to be reprinted in the ICCMO anthology and in Sleep and Health Journal where it is available at no charge @ http://www.sleepandhealth.com/neuromuscular-dentistry

Neuromuscular Dentistry is a valuable tool that helps clinicians in diagnosing and treating craniomandibular disorders. It is not the only tool. The expression that if you only have a hammer everyone looks like a nail describes what happens when a neuromuscular dentist does not remove his/her blinders and see the big picture. The hammer is an extremely effective tool, but only one of many.

Do not let your life slip by marred by chronic pain that may be alleviated or eliminated by judicious application of neuromuscular dentistry.

In the same way Neuromuscular Dentistry is an important tool (maybe even the most important tool) but it is certainly not the only tool. Experienced neuromuscular dentists utilize a wide variety of approaches in treating their patients to a neuromuscular position to obtain the best possible results.

TREAT HEADACHES, MIGRAINES AND FACIAL PAIN WITHOUT DANGEROUS DRUGS AND ASSOCIATED SIDE EFFECTS. NEUROMUSCULAR DENTISTRY IS A SAFE AND EFFECTIVE.

Neuromuscular Dentistry may be one of the most effective treatments for a wide variety of conditions including various types of "migraine", tension-type headaches, facial pain, trigeminal neuralgia, TMJ disorders, myofascial ain and muscular and neurogenic headaches. Drugs do not cure the underlying problems that cause the problems and frequently their mechanism of action is unknown. Many drugs are recalled due to dangerous or deadly side effects and a large number of patients experience rebound headaches. These patients frequently require higher doses of medication over time.

There are many varied and diverse advantages to neuromuscular dentistry over standard medical approaches. The single biggest problem in treating headaches utilizing neuromuscular dental technology is that it can be expensive. Insurance companies are aware that 50% reduction in symptoms almost always occurs with treatment. This is a higher positive respone than almost any drug regimens. Insurance companies frequently chose to deny coverage to increase profits to shareholders. Patients who have undergone numerous CAT Scans, MRI's ,Drug therapies and surgeries without adequate control of their pain frequently find that Neuromuscular Dentistry gives amazing relief and improves the quality of their lives and the lives of their loved ones and are then denied coverage for treatment. Many of these patients have exhausted their resources on unsuccessful therapies prior to learning about and experiencing relief thru neuromuscular dentistry.

The Alliance of TMD Organizations is working to address the unfair practices of insurance companies relative to the treatment of TMJ disorders and Headaches related to the masticatory system. They are also the primary group protecting the rights of TMJ patients. There is a large group of clinicians in dentistry who believe the problems patients experience are psychosocial and not physical and want medication to become the only treatment available to most patients. They would like to take away patients right to chose non-drug alternative treatments. Unfortunately this group has enormous political influence and exert control over most research funds often to the detriment of patients. This remains true even after scandals in FDA hearings led removal of some of their members from FDA panels. There are also numerous instances of unethical conflicts of interest that were not disclosed to the FDA. Additional information on the TMD alliance is available at: http://www.tmdalliance.org/

I would like to disclose that I am a representative of ICCMO to the Alliance and that I am a long term member of The American Equilibration Society, The American Academy of CranioFacial Pain and a member of The International Academy of Comprehensive Aesthetics. I am also a Diplomate of the American Academy of Pain Management. These are member organizations of the TMD Alliance. I am the chair of the insurance reimbursement commitee.


Neuromuscular Dental Treatment of headaches is usually divided into two phases: the initial treatment phase (pain reduction and elimination) and long term stabilization (long term maintenance of improved quality of life).

The initial treatment phase includes the diagnostic protocols established by the particular neuromuscular dentist, comprehensive exam including medical histroy review (extremely important), muslce palpation exam, range of motion evaluation radiographs. The use of EMG (electomyography) and computerized mandibular scans (CMS or MKG), sonography, ultra low frequency TENS and transcranial neurostimulation are frequently useful in understanding the variable in the course of the doctor establishing a working diagnosis. More advanced practitioners frequently wil do diagnostic trigger point injections, nerve blocks or autonomic blocks such as spenopalatine ganglion blocks.

The mainstay in neuromuscular dental treatment of TMJ disorders (TMD), migraines, tension-type headaches, atypical migraine, chronic daily headaches and facial pain is the diagnostic neuromuscular orthotic. THIS ORTHOTIC IS UTILIZED TO ESTABLISH A HEALTHY "LANDING POINT" THAT HAS MINIMAL MUSCULAR AND NEUROMUSCULAR ADAPTATION. This allows the body and all of the neuromuscular components a healthy environment to heal.

Doctors do not cure patients! The best doctors remove the impediments to healing! The body than returns to a healthy homeostatic condition. This is what is accomplished with the neuromuscular orthotic over a series of several appointment. If the patient experiences complete relief and /or total elimination of symptoms for an extended period the stabilization phase can be initiated. When patient have substantial relief but still have remaining symptoms they will determine whether they are ready for stabilization.

Long term stabilization can be a very expensive full mouth reconstruction but this is usually one of many possible treatments. Long term removable orthotics, orthodontics and semi-permanent appiances allow pain control without the expense of a reconstruction. WHAT IS IMPORTANT IS THAT THE PATIENT IS READY FOR LONG TERM STABILIZATION. The diagnostic orthotic is not a long term treatment. Frequently patients have dramatic improvements with their orthotics but do not precede to long term stabilization and see their symptoms return as the appliance wears down or breaks.

Sleep disturbances frequently accompany craniomandibular disorders and headaches. Patients with tiredness, morning headaches, nocturnal headaches, high blood pressur and memory problems usuallly need to be evaluated at a sleep lab utilizing a full polysomnograph array.

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

PMID: 20488748 [PubMed - indexed for MEDLINE]

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

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

PMID: 19596599 [PubMed - indexed for MEDLINE]

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

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