TRIGEMINAL AUTONOMIC CEPHALGIAS, Chronic Headaches Related To Trigeminal Nerve Respond well to Neuromuscular Dentistry & Sphenopalatine Ganglion Block

The Trigeminal Nerve is often called the Dentist's Nerve because it goes to the teeth, jaw muscles, jaw joints (TMJ),and periodontal ligament. Trigeminal innervation of the sinuses, eustacian tubes, tensor of the ear drum (tensor tympani), soft palate, tongue and meninges of the brain explain why there are so many disorders associated with jaw function, TMJ and TMD.

There are a special group of disorders called the Trigeminal Autonomic Cephalgias (See National Institute of Neurological Disorders and Stroke web information below). Sphenopalatine Ganglion Blocks are an autonomic block that can be used to treat many types of migraine, Tension-tyoe headaches and chronic daily headaches but the SPG block are especially useful for autonomic cephalgias.

Cluster Headaches are primarily found in males and frequently awake patients from sleep. Oxygen is also an excellent treatment if it is administered immediately. Triptans, neurosurgery as well as antipsychotics and calcium channel blockers are also used prophylactically. Utilization of implanted electrodes and or neurosurgery where the nerves are resected are techniques that are often used. The Sphenopalatine Ganglion block (an autonomic block can be used both diagnostically and therapeutically) is probably one of the safest and most effective treatments for cluster headaches and when done with plain lidocaine are almost free of side effects. Paroxysmal hemicrania and SUNCT (Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing) are other Autonomic trigeminal that have similarities to cluster headaches. The National Institute of Neuromuscular Disorders and Stroke can be found below)

A diagnostic neuromuscular orthotic can also be utilized prophylactically with cluster headaches. A diagnostic neuromuscular orthotic is used to treat both the sommatic and autonomic aspects of the trigeminal nerves. They are particularly effective at treating muscle spasm, myofascial pain and trigger points in masticatory muscles. The combination of both therapies, a diagnostic neuromuscular orthotic and self administered autonomic Sphenopalatine Ganglion Blocks (SPG Block) can virtually "Cure" cluster headaches in some patients. An added advantage to the diagnostic orthotic is that it can frequently eliminate tension-type headaches and chronic daily headaches (muscular orgin headaches) that are almost always trigeminally modulated.

The SPG block is a simple procedure that my patients learn to self administer in one or two appointments. The block is done transmucosally with a cotton tipped applicator with lidocaine (no epinephrine or preservatives). No needles ever penetrate the patient but rather the saturated cotton is passed intranasally (though the nose) to the area adjacent to the ganlion. The anaesthetic passes through the tissue to the ganglion.

According to Wikipedia the Sphenopalatine Ganglion is also called the "The pterygopalatine ganglion (Synonym: ganglion pterygopalatinum, meckel's ganglion, nasal ganglion, sphenopalatine ganglion) is a parasympathetic ganglion found in the pterygopalatine fossa. (This is where the cotton tip applicator contacts mucosa) It is one of four parasympathetic ganglia of the head and neck. The others are the submandibular ganglion, otic ganglion, and ciliary ganglion. The flow of blood to the nasal mucosa, in particular the venous plexus of the conchae, is regulated by the pterygopalatine ganglion and heats or cools the air in the nose.

(The structure of the Sphenopalatine Ganglion also from Wikipedia below)

The pterygopalatine ganglion (of Meckel), the largest of the parasympathetic ganglia associated with the branches of the Maxillary Nerve (branch of trigeminal nerve), is deeply placed in thepterygopalatine fossa, close to the sphenopalatine foramen. It is triangular or heart-shaped, of a reddish-gray color, and is situated just below the maxillary nerve as it crosses the fossa.

The pterygopalatine ganglion supplies the lacrimal gland (tear ducts), paranasal sinuses, glands of the mucosa of the nasal cavity and pharynx, the gingiva, and the mucous membrane and glands of the hard palate. It communicates anteriorly with the nasopalatine nerve.

According to Wikipedia (below) there are sensory, sympathetic and parasympatheic roots

Its sensory root is derived from two sphenopalatine branches of the maxillary nerve; their fibers, for the most part, pass directly into the palatine nerves; a few, however, enter the ganglion, constituting its sensory root.

Parasympathetic root

Its parasympathetic root is derived from the nervus intermedius (a part of the facial nerve) through the greater petrosal nerve.

In the pterygopalatine ganglion, the preganglionic parasympathetic fibers from the greater petrosal branch of the facial nerve synapse with neurons whose postganglionic axons, vasodilator, and secretory fibers are distributed with the deep branches of the trigeminal nerve to the mucous membrane of the nose, soft palate, tonsils, uvula, roof of the mouth, upper lip and gums, and upper part of the pharynx. It also sends postganglionic parasympathetic fibers to the lacrimal nerve (a branch of the Ophthalmic nerve, also part of the trigeminal nerve) via the zygomatic nerve, a branch of the maxillary nerve (from the trigeminal nerve), which then arrives at the lacrimal gland.

The nasal glands are innervated with secretomotor from the nasopalatine and greater palatine nerve. Likewise, the palatine glands are innervated by the nasopalatine, greater palatine nerve and lesser palatine nerves. The pharyngeal nerve innervates pharyngeal glands. These are all branches of maxillary nerve.

Sympathetic root

The ganglion also consists of sympathetic efferent (postganglionic) fibers from the superior cervical ganglion. These fibers, from the superior cervical ganglion, travel through the carotid plexus, and then through the deep petrosal nerve. The deep petrosal nerve joins with the greater petrosal nerve to form the nerve of the pterygoid canal, which enters the ganglion.

TRIGEMINAL AUTONOMIC CEPHALGIAS

Some primary headaches are characterized by severe pain in or around the eye on one side of the face and autonomic(or involuntary) features on the same side, such as red and teary eye, drooping eyelid, and runny nose. These disorders, called trigeminal autonomic cephalgias (cephalgia meaning head pain), differ in attack duration and frequency, and have episodic and chronic forms. Episodic attacks occur on a daily or near-daily basis for weeks or months with pain-free remissions. Chronic attacks occur on a daily or near-daily basis for a year or more with only brief remissions.

Cluster headache - the most severe form of primary headache-involves sudden, extremely painful headaches that occur in "clusters," usually at the same time of the day and night for several weeks. They strike one side of the head, often behind or around one eye, and may be preceded by a migraine-like aura and nausea. The pain usually peaks 5 to 10 minutes after onset and continues at that intensity for up to 3 hours. The nose and the eye on the affected side of the face may get red, swollen, and teary. Some people will experience restlessness and agitation, changes in heart rate and blood pressure, and sensitivity to light, sound, or smell. Cluster headaches often wake people from sleep.

Cluster headaches generally begin between the ages of 20 and 50 but may start at any age, occur more often in men than in women, and are more common in smokers than in nonsmokers. The attacks are usually less frequent and shorter than migraines. It's common to have 1 to 3 cluster headaches a day with 2 cluster periods a year, separated by months of freedom from symptoms. The cluster periods often appear seasonally, usually in the spring and fall, and may be mistaken for allergies. A small group of people develop a chronic form of the disorder, which is characterized by bouts of headaches that can go on for years with only brief periods (1 month or less) of remission. Cluster headaches occur more often at night than during the day, suggesting they could be caused by irregularities in the body's sleep-wake cycle. Alcohol (especially red wine) and smoking can provoke attacks. Studies show a connection between cluster headache and prior head trauma. An increased familial risk of these headaches suggests that there may be a genetic cause.

Treatment options include oxygen therapy-in which pure oxygen is breathed through a mask to reduce blood flow to the brain-and triptan drugs. Certain antipsychotic drugs, calcium-channel blockers, and anticonvulsants can reduce pain severity and frequency of attacks. In extreme cases, electrical stimulation of the occipital nerve to prevent nerve signaling or surgical procedures that destroy or cut certain facial nerves may provide relief.

Paroxysmal hemicrania is a rare form of primary headache that usually begins in adulthood. Pain and related symptoms may be similar to those felt in cluster headaches, but with shorter duration. Attacks typically occur 5 to 40 times per day, with each attack lasting 2 to 45 minutes. Severe throbbing, claw-like, or piercing pain is felt on one side of the face-in, around, or behind the eye and occasionally reaching to the back of the neck. Other symptoms may include red and watery eyes, a drooping or swollen eyelid on the affected side of the face, and nasal congestion. Individuals may also feel dull pain, soreness, or tenderness between attacks or increased sensitivity to light on the affected side of the face. Paroxysmal hemicrania has two forms: chronic, in which individuals experience attacks on a daily basis for a year or more, and episodic, in which the headaches may stop for months or years before recurring. Certain movements of the head or neck, external pressure to the neck, and alcohol use may trigger these headaches. Attacks occur more often in women than in men and have no familial pattern.

The nonsteroidal anti-inflammatory drug indomethacin can quickly halt the pain and related symptoms of paroxysmal hemicrania, but symptoms recur once the drug treatment is stopped. Non-prescription analgesics and calcium-channel blockers can ease discomfort, particularly if taken when symptoms first appear.

SUNCT (Short-lasting, Unilateral, Neuralgiform headache attacks with Conjunctival injection and Tearing) is a very rare type of headache with bursts of moderate to severe burning, piercing, or throbbing pain that is usually felt in the forehead, eye, or temple on one side of the head. The pain usually peaks within seconds of onset and may follow a pattern of increasing and decreasing intensity. Attacks typically occur during the day and last from 5 seconds to 4 minutes per episode. Individuals generally have five to six attacks per hour and are pain-free between attacks. This primary headache is slightly more common in men than in women, with onset usually after age 50. SUNCT may be episodic, occurring once or twice annually with headaches that remit and recur, or chronic, lasting more than 1year.

Symptoms include reddish or bloodshot eyes (conjunctival injection), watery eyes, stuffy or runny nose, sweaty forehead, puffy eyelids, increased pressure within the eye on the affected side of the head, and increased blood pressure.

Cephalalgia. 2009 Jul 13. [Epub ahead of print] LinksSluder's neuralgia: a trigeminal autonomic cephalalgia?

SUNCT is very difficult to treat. Anticonvulsants may relieve some of the symptoms, while anesthetics and corticosteroid drugs can treat some of the severe pain felt during these headaches. Surgery and glycerol injections to block nerve signaling along the trigeminal nerve have poor outcomes and provide only temporary relief in severe cases. Doctors are beginning to use deep brain stimulation (involving a surgically implanted battery-powered electrode that emits pulses of energy to surrounding brain tissue) to reduce the frequency of attacks in severely affected individuals.

Oomen KP, van Wijck AJ, Hordijk GJ, de Ru JA.
Department of Otolaryngology, Central Military Hospital, Utrecht, The Netherlands.
Oomen KPQ, van Wijck AJM, Hordijk GJ & de Ru JA. Sluder's neuralgia: a trigeminal autonomic cephalalgia? Cephalalgia 2009. London. ISSN 0333-1024The objective was to formulate distinctive criteria to substantiate our opinion that Sluder's neuralgia and cluster headache are two different clinical entities. A systematic review was carried out of all available, original literature on Sluder's neuralgia. Pain characteristics, periodicity and associated signs and symptoms were studied and listed according to frequency of appearance. Eleven articles on Sluder's neuralgia were evaluated. Several differences between Sluder's neuralgia and cluster headache became evident. Based on described symptoms, new criteria for Sluder's neuralgia could be formulated. Sluder's neuralgia and cluster headache could possibly be regarded as two different headache syndromes, and Sluder's neuralgia could be a trigeminal autonomic cephalalgia.
PMID: 19614698 [PubMed - as supplied by publisher]

TMJ disorders, headaches and facial pain frequently involve cervical musculature. Acute pain relief is accomplished with cervical muscle injection

An article (pubmed abstract below) in the Journal of Orofacial Pain. "Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients." dicusses the use of cevical intramuscular injections to turn off acute pain in the ER. The study showed that 94% of patients had complete of partial relief with injection of a long acting anaesthetic.

There is a connection between the jaw and the neck that is incredibly important in the treatment of muscular headaches, facial pain, migraines, chronic daily headaches and TMJ disorders (TMD). The jaw acts as a counter-balance to the head and allows maintenance of head posture minimal excessive muscle adaptation. This is well described mathematically in engineering terms in the "Quadrant Theorem of Guzay". The jaw position is vital to body posture and abberations in jaw position can act as a descending disorder that can effect the entire body.

Forward head posture is frequently seen in TMJ and Headache patients. This forward posture cause exponential increases in muscle work just to maintain head posture.

Rcobado estimated that it takes double the muscle work from cervical muscles to low back for every centimeter of forward head posture, Three centimeters forward head posture would increase chronic muscle adaptation 8 fold (2X2X2=8) while a 5 centimeter forward head posture would increase it 32 times (2X2X2X2X2=32). The reason muscular injections work so well in relieving acute and chronic headaches and facial pain is that these muscles are grossly overworked in TMD patients.

Treating the muscles can give relief of acute pain but returning the system to a more normal physiologic state can give long term relief to patients.

A diagnostic neuromuscular orthotic allows the jaw to function in an ideal physiologic position. This allows gradual restoration of normal head posture and a return to normal physiologic function of the neck. I work closely with Atlas Orthogonal and/or NUCCA Chiropracters to correct the first two vertebrae early in treatment. These areas are especially prone to problems in TMD patients. As the foward head posture occurs the patient must rotate their head on the Atlas and Axis (first to vertebrae) to maintain sight lines. This is well explained by the Quadrant Theorem of Guzay which shows that the actual center of rotation for the jaw when both rotation and traslation movements are calculated is on the odontoid process of the Axis (2nd vertebrae)

Patients with TMD who are in car accidents never recover fully if their jaw issues are not addressed.

Posturology is the study of whole body posture. Posturology recognizes the importance of the jaw position. The normal swallow is a neuromuscular resetting procedure but most TMD patients have deviant or reversed swallows and are not even aware they swallow wrong. This can lead to GI problems but is primarily a structural problems that makes long term successful treatment of pain impossible without correction of neuromuscular jaw issues. A diagnostic orthotic allows patients to experience relief of head and neck pain prior to and permenant occlusal alterations.


J Orofac Pain. 2008 Winter;22(1):57-64.
Treatment of acute orofacial pain with lower cervical intramuscular bupivacaine injections: a 1-year retrospective review of 114 patients.
Mellick LB, Mellick GA.
Source
Department of Emergency Medicine, Medical College of Georgia, Augusta, Georgia, USA. lmellick@mcg.edu
Abstract
AIMS:
To describe 1 year's experience in treating orofacial pain with intramuscular injections of 0.5% bupivacaine bilateral to the spinous processes of the lower cervical vertebrae.

METHODS:
A retrospective review of 2,517 emergency department patients with discharge diagnoses of a variety of orofacial pain conditions and 771 patients who were coded as having had an anesthetic injection between June 30, 2003 and July 1, 2004 was performed. The records of all adult patients who had undergone paraspinous intramuscular injection with bupivacaine for the treatment of an orofacial pain condition were extracted from these 2 databases and included in this retrospective review. Pain relief was reported in 2 different ways: (1) patients (n = 114) were placed in 1 of 4 orofacial pain relief categories based on common clinical experience and face validity and (2) pain relief was calculated based on patients' (n = 71) ratings of their pain on a numerical descriptor scale before and after treatment.

RESULTS:
Lower cervical paraspinous intramuscular injections with bupivacaine were performed in 118 adult patients. Four charts were excluded from review because of missing or inadequate documentation. Pain relief (complete or clinical) occurred in 75 patients (66%), and partial orofacial pain relief in 32 patients (28%). No significant relief was reported in 7 patients (6%). Overall, some therapeutic response was reported in 107 of 114 patients (94%). Orofacial pain relief was rapid, with many patients reporting complete relief within 5 to 15 minutes.

CONCLUSION:
This is the first report of a large case series of emergency department patients whose orofacial pain conditions were treated with intramuscular injections of bupivacaine in the paraspinous muscles of the lower neck. The findings suggest that lower cervical paraspinous intramuscular injections with bupivacaine may prove to be a new therapeutic option for acute orofacial pain in the emergency department setting.

Gurnee Dental Office Utilizes Neuromuscular Dentistry to Treat TMJ, TMD, Chronic Headaches and Migraines

I have been practicing Neuromuscular Dentistry in Gurnee since 1984. My Partner, Dr Mark Amidei has an additional 20 years experience in Neuromuscular Dentistry. In addition to treating, eliminating and/or preventing headaches and migraines Neuromuscular Dentistry is excellent for treating TMJ disorders (TMD) and also for creating neck stability.

I frequently work with chiropracters and the combination of therapy can give phenomenal results.

Many people do not understand what Neuromuscular Dentistry is, so I am reprinting an article I wrote here that was originally published by the AES or American Equilibration Society and republished in the ICCMO Anthology and by Sleep and Health Journal. Additional information about Neuromucular Dentistry is available at our dental website at http://www.delanydentalcare.com/neuromuscular.html


NEUROMUSCULAR DENTISTRY (originally published in the American Equilibration Society magazine)

Ira L Shapira DDS, DABDSM, DAAPM, FICCMO

Neuromuscular Dentistry remains an enigma to many dentists who do not understand the purposes of the electrodes, the TENS, the computers and more. It has unfairly become a target of poor and misleading definitions by doctors who do not understand its basic principles.

There are several basic premises that underlie Neuromuscular Dentistry. The first premise is that the stomatognathic muscles are the primary determinate of the mandibles position during all jaw functions (when the teeth are not in occlusion) and that rest position is one of the most important positions in dentistry. Rest position is a maxillary to mandibular jaw relation where the teeth are not in occlusion but are prepared to occlude. In Neuromuscular Dentistry Rest is a position of bilaterally equal and low muscle tonicity from which the mandible moves into full occlusion with minimal muscle accommodation. Following closure from rest position the mandible should return to rest with similarly balanced low muscle tonicity. Rest position is determined not only by the mandible’s relation to the cranium but also by the position of the head relative to the body, the suprahyoid and infrahyoid muscles and the position of the hyoid bone. To fully understand the relation of jaw movement to head posture read the Quadrant Theorem of GUZAY (Available from the ADA Library). In essence it shows in engineering terms that after accounting for both rotation and translation of the mandible the actual axis of rotation of the mandible is at the odontoid process of the second vertebrae not at the mandible condylar head.

The second premise is that occlusion is important in neuromuscular dentistry as a resetting mechanism of the trigeminal nervous system’s control of the stomatognathic muscles. Myocentric occlusion is ideally a position in which the muscles move the mandible from a non-torqued rest position into full occlusion with minimal muscle accommodation and no interferences of occlusal contacts until full closure is attained thus eliminating all torque during closure. This means that there are no noxious contacts received by the periodontal ligaments or the muscular proprioceptors that must be avoided by the muscles (accommodation) but rather allow “free” entry into myocentric occlusion. The jaw muscles will return to rest position after closure with the muscles maintaining their healthy low tonicity. Relaxed healthy musculature is the gold standard of neuromuscular dentistry.

Swallowing is a primary activity when the jaw is closed into full occlusion. In order to swallow it is necessary to fixate the mandible and this happens as the teeth occlude. During chewing, speaking and other jaw functions the teeth do not actually occlude in normal function but are separated (during chewing by a bolus of food). Typically swallowing occurs approximately 2000 times a day and is momentary accounting for 6-10 minutes maximum time in occlusion over the course of the day and acts as a neuromuscular reset switch for trigeminally innervated muscles. During a healthy swallow the teeth will move freely without interference into full occlusion with bilateral equal contact and bilateral equal muscle activity and then return to rest position with low muscle tonicity. A deviate swallow as evidenced by scalloping of the tongue is a sign of a possible TMJ disorder and is also 80% predictive of sleep apnea (80% predictive in Dental study- 70% predictive ENT study)

Neuromuscular occlusion (myocentric) occurs when centric occlusion (maximum non-torqued intercuspation of teeth) is coincidental with a balanced muscle closure where the muscles will return to their relaxed state following closure. Myocentric is the ideal position for swallowing.

The dentist utilizing neuromuscular techniques does not determine a specific position of the condyles in the fossa. The position of the disk and condyle are determined primarily by the teeth (bite or orthotic during occlusal correction therapy) in occlusion (myocentric) and the application of muscle activity. Neuromuscular dentistry allows the patients healthy relaxed muscles to determine the joint relations with the teeth serving as a neuromuscular reset switch during closure. Neuromuscular dentistry rejects the notion that manipulation of the patient’s jaw by the intervention of the clinician muscles are more important in determining the relation of the components of the TM Joint than the muscles of the patient. Centric relation is not used as a reference position for mounting casts on an articulator. Centric Relation is considered a border movement of the mandible and as reported in orthopedic literature joints are rarely used in their border positions.

The HIP plane (defined by hamular notches, incisive papilla and the occipital condyles) and/or Campers plane is used to relate the maxilla to an articulator. When cosmetic considerations are involved photos are used to to incorporate this physiologic plane to soft tissues of the face. Ideally the occlusal plane (parallel to the HIP Plane) will bisect the odontoid process of the axis of the atlantoaxial joint the actual center of rotation for the mandible after accounting for translation and rotation according to the quadrant theorem.

This occlusal plane will be at a 90-degree angle to gravitational force when the head is in an upright position. A neuromuscular bite is used to mount the


mandibular casts according to data from EMG recordings and jaw tracings with TENS. The incorporation of the Curve of Spee based on Centro Masticale (CM) point which continues thru the mandibular condyle and the Curve of Wilson also based on CM point that is involved is stimulation of the autonomic nervous system via tongue reflexes when the lateral border of the tongue touches the lingual surfaces of the teeth. (Critical Reviews in Oral Biology & Medicine, Vol. 13, No. 5, 409-425 (2002)) This excellent article is available online at http://cro.sagepub.com/cgi/content/full/13/5/409

Neuromuscular dentistry considers many of the problems associated with TMD to be repetitive strain injuries. Movements become harmful when closure requires excessive accommodation and then the system fails at its weakest link. If the weakest link is muscle health we will see formation of tender sore muscles with eventual formation of taut bands and trigger points. If there is muscle overuse from clenching and/or grinding there will be post exercise pain secondary to anaerobic lactic acid build-up. If the weakest point is in the TM Joint then when repetitive strain occurs the muscle accommodation will lead to increased intra-articular pressure. This again will break down the joint at its weakest point. This may occur as a displaced disk or as wear of articular surfaces or many other conditions. It may come at the expense of the bone of the condyle leading to flattening or beaking of the condyle. Clenching and bruxism are two particularly well-known and harmful parafunctional habits that lead to varied repetitive strain injuries. There are many other parafunctions that can lead to problems. Some parafunctions are actually protective muscle accommodation such as the deviated or reversed swallow that protects the TM Joints and masticatory muscles at the expense of altered head, hyoid and spine position and consequent muscle problems.

The second type of problems would be described as I/O or Input/ output errors in computer lingo. The CNS is essentially a biological computer and is affected by input from afferent nerves from the body. Autonomic system function include the fight or flight response with concomitant release of adrenaline that alters the heart rate, blood pressure, muscle tone etc. This system effects the Hypothalamus pituitary complex with feedback to the adrenals and effects on ACTH and cortisol levels. During periods of acute stress these effects have a positive survival value but during chronic stress become a liability to the individual as described by Hans Selye in his book “The Stress of Life” and his discussion of the General Adaptation Syndrome. There are numerous biochemical changes that occur in the brain secondary to aberrant or nociceptive input into the brain these can be affected by correction of the neurological input, by using drugs to change the brain chemistry or a combination of these approaches. Ideally correction of the underlying cause of these biochemical changes is the preferred method of treatment.

The utilization of TENS or transcutaneous neural stimulation over the coronoid notch has been shown by Mitani and Fujii (1974 J. Dent Res.) to block the motor division of the trigeminal nerve and relax the musculature via anti-dromic impulses (hyperpolarisation) to both the alpha and gamma motor neurons without influence from proprioceptive and nocioceptive (tooth contacts) inputs The TENS is then use to create a balanced synchronize pulsing to find the trajectory of closure where a myocentric registration can be obtained. The muscles will return to their relaxed position following closure into myocentric.

The use of Computerized mandibular jaw tracking allows the dentist to measure and record resting jaw position relative to the cranium at a given head position. The location of myocentric occlusion is determined by the dentist with the aid of information from tracings recorded.

Electromyography or EMG is used to record relative values of resting muscle activity of masticatory muscles as well as muscles such as Sternocleidomastoid or Trapezius. While there are no absolute “normal values” of resting muscles the clinician uses his information to compare muscle activity within a given patient. Muscles should be approximately equal activity bilaterally. Thomas 1990 in Frontiers of Oral Physiology vol 7 pp162-170 demonstrated that Spectral analysis of the post TENS EMG may be utilized to evaluate muscle fatigue and differentiate between muscle atrophy or fatigue or relaxed muscle states. This was later confirmed by Frucht, Jonas and Kappert at Frieberg University in 1995 (Fortschr.Kieferorthop vol 56 pp 245-253)

Utilizing the two modalities together allows the clinician to evaluate the rest position of the jaw and simultaneously the health and functional activity of the muscles.

The EMG also allows tests to evaluate the functional capacity of the muscles and again compare the right and left sides for symmetry. The use of functional recordings (during clenching and closure into centric occlusion) allows the clinician to evaluate whether or not muscle function is satisfactory and functional. The use of EMG also allows evaluation and correction of first contact of closure position within microseconds bases on firing order of the masseter and temporalis muscles. The first point of contact on closure is vitally important and equilibration of orthotics and dentition must be finely adjusted until first contact is evenly dispersed on posterior dentition.

Neuromuscular dentistry is very concerned with the effects of mandibular position on the body as a whole and on the effects of the body on jaw and head position. The work of Sherrington and the righting reflex explains how ascending and descending disorders affect a patient. These phenomena have been best explained by Norman Thomas BDS, PhD. I will not attempt to explain this complicated topic in this agenda, which may be found in Anthology of ICCMO vol V pp159-170. It obviously must incorporate the Quadrant Theorem of Casey Guzay, the physiological aspects of the balance organ of the inner ear and the vestibular apparatus located in the brainstem as well as visual feedback. The control of sympathetic and parasympathetic systems by the cerebellum is quite intricate and also affected by head position.

Correction of the chewing cycle is an important part of occlusal finalization. It must be understood that the chewing cycle is different on the each side and that interferences can occur on both the opening and closing strokes of the chewing cycle. Interferences in chewing strokes are easiest to detect by study of the chewing strokes on computerized mandibular scans (MKG). Head position during chewing is not is normally in the upright head position but in the feeding position approximately a 30-degree anterior head flexion. Correction of the chewing cycle is at least as important as correction of right, left and protrusive excursions. Chewing is a healthy function of the craniomandibular apparatus where as excursive movements are actually exercises in parafunctional movements.

There is more commonality to treatment of TMJ disorders by neuromuscular and non-neuromuscular dentists than differences and complications caused by neural intensification in the reticular activating system, emotional aspects and the relation to the limbic system, connections to the sympathetic and parasympathetic nervous systems via the Sphenopalatine Ganglion and sympathetic chain, and chemical changes and cerebroplastic changes that occur during chronic pain leading to hyperalgesia and allodynia all can be discussed in greater detail and explained in relation to neuromuscular dentistry. The basics physiology including effects of Golgi tendon organs and muscle spindles on jaw muscles remain constant and must always be carefully considered during treatment.

Barney Jankelson’s famous quote, “if it is measured it is a fact otherwise it is an opinion “ rings as true today as when he first said it. Neuromuscular dentistry is about making accurate measurements and the use of those measurements to improve the doctor’s ability to make a differential diagnosis and tailor treatment to relieve pain and create stable restorative dentistry with healthy relaxed musculature.

I would like to make a disclaimer that this is my personal definition of Neuromuscular dentistry from 30 years of practice and to thank my mentors Barney Jankelson, Barry Cooper, Dayton Krajiec, Richard Coy, Harold Gelb, Peter Neff, Robert Jankelson and especially Jim Garry who first made me understand the connections between increased upper airway resistance and the common developmental aspects of sleep apnea and craniomandibular disorders. A special thank you for Dr Norman Thomas for his extraordinary help in understanding the complex physiology and anatomy underlying neuromuscular dentistry and in reviewing this paper prior to presentation.

My personal research in the 1980’s as a visiting assistant professor at Rush Medical School examined the jaw relations of patients with obstructive sleep apnea based on neuromuscular evaluations of jaw relations with a Myotronic's kinesiograph and a myomonitor to find neuromuscular rest position. These studies showed jaw relations in the male apnea patients that were strikingly similar to those found in female TMD patients. The National Heart Lung and Blood Institute considers sleep apnea to be a TMJ disorder. The NHLBI published a report, “Cardiovascular and Sleep Related Consequences of TMJ Disorders” in 2001 that can be found at
http://www.nhlbi.nih.gov/meetings/workshops/tmj_wksp.pdf

Dr Shapira returned to Rush as an assistant professor at the sleep center in the 1990’s where he treated a wide variety of obstructive apnea patients with commercial and customized intraoral sleep appliances. He was a founding and credentialed member of the Sleep Disorder Dental Society that has become the American Academy of Dental Sleep Medicine, He is a Diplomate of the American Board of Dental Sleep Medicine, on the board of the Illinois Sleep Society, a Diplomat of the American Academy of Pain Management, a Regent Fellow of the International College of Cranio-Manibular Orthopedics and a representative of that group to the TMD Alliance. He is a long time member of AES, AACFP, Academy of Sleep Medicine and the Chicago Dental Society. Dr Shapira teaches hands-on in-depth Dental Sleep Medicine courses to small groups at his Gurnee office. A family history of genetic cancer led Dr Shapira into research on stem cells an he also holds several patents (method and device) on the collection of stem cells during early minimally invasive removal of the uncalcified tooth bud of developing third molars. This procedure can be complete in minutes with greatly reduced morbidity compared to current surgical techniques used for removal of developed third molars. He hopes in the future that patients will routinely remove the tooth buds and collect and save the stem cells for anti-aging and regenerative medical uses.

For more information on headache diagnosis and treatment as related to neuromuscular dentistry, please read the entire I Hate Headaches Website

Neuromuscular Dentistry does have some illustrations that are reprinted at the Sleep and Health Journal site at:
http://www.sleepandhealth.com/neuromuscular-dentistry

Quality of Life Destroyed By Chronic Daily Headache according to Cephalgia article. Neuromuscular Dentistry can improve Quality of Life

A total of 34 studies were reviewed in this paper. Chronic Daily Headache (CDH) and Chronic Daily Headache with Medication Overuse (MOH) consistently created a lower quality of life. The Cephagia Article "Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review." include 25 studies of patients and 9 studies of the general population.

I strongly recommend Neuromuscular Intervention as soon as possible when chronic headaches begin. These studies clarify the importance of utilizing a diagnostic neuromuscular orthotic early in the course of the problem. Almost every study done on headache treatment with a neuromuscular diagnostic orthotic shows at least a 50-80% improvement with NMD and frequently far superior results than medication.

Chronic Daily Headache frequently responds extremely well to Neuromuscular Dentistry but unfortunately a diagnostic orthotic is rarely offered to patients in pain centers and neurology offices. The biggest complaint about Neuromuscular Dentistry is that it can be expensive and time consuming when compared to writing a perscription. Long term savings and improvement in quality of life are essential considerations that must be taken into consideration. Insurance companies frquently are uncooperative using sneaky contract language to deny medically necessary treatment. One of the most common and unquetionably fraudulant techniques is to call all headaches and migraines treated by a dentist TMJ or TMD and then place an artificially low coverage maximum on that treatment. The article clearly states "Chronic Daily Headache was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than Episodic Headache, it is essential."

The principal conclusions of this review were"the findings of this review underline the detriment to Quality of Life and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache."

Reducing medication use and overuse is one of the real advantages of Neuromuscular Dental treatment of Chronic Migaine and Chronic Daily Headache. The side effects of massive drug use in headache and migraine often worsen the problem.

Prior to treating migraines, Tension -type headaches sinus headaches, and chronic daily headaches with dangerous medications it is logical to utilize a Dignostic Neuromuscular Orthotic, if relief is obtained the Medication Overuse is diminished. Medication Overuse Headaches are one of the worst headache types in destroying quality of Life.

The Neuromuscular Dental Institute (Institute for the Study of Neuromuscular Dentistry) is my answer to this disaster. Dr Barry Cooper, a leading Neuromuscular Dentistry Educator will teach his introduction to Neuromuscular Dentistry course to small groups of 4-6 dentists. We hope large numbers of these students will continue their Neuromuscular Dental Education at ICCMO (International College of CranioMandibular Orthopedics) meetings and at the Las Vegas Institue (LVI)

This wll be in addition to the current course I give on Sleep Apnea Treatment with oral appliance (Dental Sleep Medicine) as well as coverage of nerve blocks including the SPG block. The SPG or Sphenopalatine Ganglion Block can be incredibly effective in preventing and eliminating migraines. Ideally patients can learn to utilze and self administer SPG blocks to prevent or Amelliorate migraine headaches early in their course. It is simple, inexpensive and frequently incredibly effective.

The Alliance of TMD organizations (I am the ICCMO representative to the TMD Alliance) is working to prevent patients from being denied care that will mprove their overall quality of life and subsequently result in enormous long term savings in costs and expenses associates with chronic headaches and migraines.

The way TMJ, TMD and Neuromuscular Dentistry is dealt with by insurance companies is an example of Discrimination against women since the vast majority of patients with headaches, migraines and TM Joint disorders are female.

I will continue to treat patients at my Gurnee Dental practice, Delany Dental Care Ltd in our current locatin and in our new location that has a better layout for giving continuing educational courses to dentists, physicians and allied medical practitioners. Contact my office at 847-623-5530 for information on becoming a patient.

We do make special arrangements for long distance patients to make treatment requre less time and travel.

Ira L Shapira DDS, D,ABDSM, D, AAPM, FICCMO


Pub Med Abstract follows:

Cephalalgia. 2011 Apr 4. [Epub ahead of print]
Quality of life impairment, disability and economic burden associated with chronic daily headache, focusing on chronic migraine with or without medication overuse: A systematic review.
Lantéri-Minet M, Duru G, Mudge M, Cottrell S.

CHU de Nice - Hôpital Pasteur, France.
Abstract
Objective : To evaluate the evidence for quality of life (QoL) impairment, disability, healthcare resource use and economic burden associated with chronic daily headache (CDH), focusing on chronic migraine (CM) with or without medication overuse. Methods : A systematic review and qualitative synthesis of studies of patients/subjects with CDH that included CM, occurring on at least 15 days per month. Main findings: Thirty-four studies were included for review (25 studies of patients and nine of subjects from the general population). CDH and CDH with medication overuse headache (MOH) were consistently associated with a lower QoL compared to control or episodic headache (EH) and CDH without MOH. CDH was consistently associated with greater disability and productivity loss, more consultations, more or longer hospitalizations and higher direct costs than EH. Data were not amenable to statistical pooling. Principal conclusions : The findings of this review underline the detriment to QoL and the disabling nature of CDH, and in particular CM and CDH with MOH, and negative impact on workplace productivity compared to other types of headache.

PMID: 21464078 [PubMed - as supplied by publisher]

TMJ AND POSTURE: THE INTIMATE CONNECTION BETWEEN CHIROPRACTIC PROBLEMS AND TMJ DISORDERS (TMD) ARE CRITICAL.

PATIENTS LIVING WITH TMJ DISORDERS, CHIROPRACTIC DISORDERS, HEADACHES AND MIGRAINES are alll suffering from the same underlying disorders. It is well recognized that it is impossible to achieve long term successful treatment without addressing both the dental, TMJ and Trigeminal components in conjunction with with the Chiropractic aspects of care.

Atlas Orthoganal Chiropractic or NUCCA chiropractic focus on the first two vertebrae. Both are excellent techniques but I usually prefer working with A/O chiropracters as they take a more universal approach to care. Many NUCCA chiropracters think that they can correct everything even though research at the prestegious Las Vegas Institue has shown that NUCCA adjustments DO NOT HOLD when the Neuromuscular Dental Occlusion is not corrected. A/o Chiropracters tend to be mor inclusive in care.

Atlas Orthoganal Chiropactic focuses on the first two vertebrae, the Atlas and the Axis. According to the website http://www.atlasorthogonality.com/index.htm the website of the Roy W Sweat Foundation:

"Atlas Orthogonal (SCALE—Stereotactic Cervical ALignment methods) is a spinal healthcare program developed by Dr. Roy Sweat in the late 1960’s based on scientific and biomechanical procedures. Dr. Sweat is considered by many to be one of the world’s foremost authorities on the cervical spine. After years of extensive research he developed a non-invasive, precision instrument to restore structural integrity from cervical vertebral malposition. The percussion instrument achieves postural restoration without manipulation or surgery. This precision treatment reduces cervical spine misalignment and its related symptomatology."

I work with two excellent A/O Chiropracters Dr Mark Freund in Lindenhurst and Dr David Menner in Lake Villa. I have also worked with severl NUCCA Chiropracters.

The connection between the Trigeminovascular system, the masticatory apparatus and the TM Joints was best described by a series ofg patients called "The Quadrant Theorem of Guzay" that describes how the actual center of rotation of the mandible (lower jaw) after accounting for both rotation and translation is on the Odontoid Process of the Axis found within the confines of the Atlas. The head rests on the Atlas on two fcets and it was named for Atlas in Greek Mythology who held the world on his shoulders.

Yoy can consider A/o Chiropracters and NUCCA Chiropracters as a herois Atlas managing the balance of the head on the top of the cervical column.

The neuromuscular Dentist is the navigator who assures that the head stays balanced so Atlas Axis stability is retained. The two treatments are intimately connected.

There are many other important areas of treatment in the body but these TOP Blocks are most important for anyone with Headaches, Migraines, TMJ, TMD, Spinal Problems, Tension-Type Headaches, SUNCY, Chronic Daily Headaches and non-infectious Sinus Pain and Sinus Headaches.

Additional information on Neuromuscular Dentistry is available at: http://www.sleepandhealth.com/neuromuscular-dentistry and at Dr Shapira's Delany Dental Care Ltd website at: http://www.delanydentalcare.com/neuromuscular.html

NEUROMUSCULAR DENTAL INSTITUTE: ANNOUNCING A NEW NEUROMUSCULAR DENTAL TRAINING INSTITUE IN CHICAGO AREA

NEUROMUSCULAR DENTAL INSTITUTE: ANNOUNCING A NEW NEUROMUSCULAR DENTAL TRAINING INSTITUTE IN CHICAGO AREA. TMJ patients in Chicago will benefit from the combined expertise of Neuromuscular Clinicians.
Treatment of Migraines, Chronic Daily Headache, TMJ, SUNCT, TMD, Tension Type Headaches, Facial Pain and Sleep Disorders

Treating patients with Migraines, Chronic Daily Headaches, Tension-Type Headache,TMJ, TMD, TMJ disorders, Fibromyalgia, Facial Pain has long been a major emphasis of my Gurnee practice, Delany Dental Care Ltd. NEUROMUSCULAR DENTAL INSTITUTE: ANNOUNCING A NEW NEUROMUSCULAR DENTAL TRAINING INSTITUTE IN CHICAGO AREA. TMJ patients in Chicago will benefit from the combined expertise of Neuromuscular Clinicians.
Treatment of Migraines, Chronic Daily Headache, TMJ, SUNCT, TMD, Tension Type Headaches, Facial Pain and Sleep Disorders

Treating patients with Migraines, Chronic Daily Headaches, Tension-Type Headache,TMJ, TMD, TMJ disorders, Fibromyalgia, Facial Pain has long been a major emphasis of my Gurnee practice, Delany Dental Care Ltd.
http://www.delanydentalcare.com/neuromuscular.html
http://www.ihateheadaches.org
http://www.ihatecpap.com

I am pleased to announce the opening of "THE INSTITUTE FOR THE STUDY NEUROMUSCULAR DENTISTRY". I have been treating patients utilizing Neuromuscular Dentistry Techniques for over 30 years after being trained by Dr Barney Jankelson the Father of Neuromuscular Dentistry, DR DAYTON KRAJAC, DR JIM GARRY, DR BARRY COOPER, DR ED DUNCAN, DR NORMAN THOMAS, DR BOB JANKELSON, DR HAROLD GELB, DR BRENDAN STACK, DR PETER NEFF are just a few of the Dental Greats I can thank for advanced training in treatng TMJ disorders over the last 34 years

I currently teach my two day sleep apnea course to small groups of dedicated dentists. I have found that true education is best in small group sessions and have limited my class size to 6 new doctors per course. (All doctors can take repeat sessions at future courses). I have given introduction to many facets of Neuromuscular Dentistry, Trigger Point Injections, Treatment of Myofascial pain during my courses. My Dental Sleep Medicine courses have always included lectures by Dr Alexander Golbin MD, PhD D,AASM and visits to the sleep lab at the Sleep and Behavioral Medicine Institute.


My exciting new development is that I have just talked to Dr Barry Cooper who has agreed to to join me and the Neuromuscular Dentistry Institute as an instructor. Dr Cooper currently teaches Neuromuscular Occlusion Workshop NOW® in New York. I have frequently referred my students to Dr Cooper as the best way to be introduced to the exciting field of Neuromuscular Dentistry. My partner Dr Mark Amidei and I are currently preparing to move into our new offices that will be better suited for educational purposes. Dr Amidei is one of the finest technical dentists who utilizes Neuromuscular Dentistry in creating exceptional cosmetic results.

Common Symptoms of Neuromuscular Dysfunction of the head and neck that can be alleviated or eliminated through Neuromuscular Dentistry include the following TMJ/TMD Symptoms:
Headaches
Migraines
Tension-type headaches
Sinus Pain and stuffiness
Facial Pain
Jaw Pain
Ear Pain
Pressure in the ears and sinuses
Clicking/Popping in Jaw Joints
Snoring
Sleep Apnea
Upper Airway Resistance Syndrome UARS or RERA's
Difficulty Chewing
Limited Mouth Opening
Uncomfortable bite
Changing bite
Tinnitus
Muffled Ears
Worn-down Teeth
Clenching/Bruxing
Neck Pain
Dizziness
Numbness in hands and arms
Myofascial Pain
Fibromyalgia
Swallowing problems
Equilibrium problems
Tics and Twitches of facial muscles
Dyskinesias
and numerous other symptoms

Dr Amidei and I have both trained at the Las Vegas Institute and the Neuromuscular Dental Institute will not be competing with LVI but rather will give doctors a jump start at achieving excellence in Neuromuscular Dentistry. We hope that many of our doctors will continue to seek out the advanced educational opportunities at the Las Vegas Institute. To understand how important I consider the addition of Dr Cooper to the Neuromuscular Dental Institute I am including his Curriculum Vitae below:

BARRY C. COOPER, DDS, First and most important Barry is a good friend and long term colleague who has been both a mentor and confidant. He is internationally recognized in the field of electronic measurements used in the treatment of TMJ / TMD, is a uniquely respected practitioner, author, researcher and educator. An innovator in the treatment of TMJ / TMD, Dr. Cooper has contributed to the knowledge and practice of dentistry as it enters a new era of advanced technology.

His accomplishments in the field of Neuromuscular Dentistry are unsurpassed including the following academic and professional appointments:

*Clinical Associate Professor, (1999-present), Department of Oral Biology & Pathology, School of Dental Medicine, SUNY, Stony Brook

*Clinical Associate Professor of Dentistry (1991-1994), Department of Prosthodontics, Temple University School of Dentistry
Associate Professor of Clinical Otolaryngology (1982-1994), Department of Otolaryngology, New York Medical College
Director, Center for Myofacial Pain/TMJ Therapy (1982-1993), Department of Otolaryngology, Head and Neck Surgery, New York Eye and Ear Infirmary

*Assistant Clinical Professor of Dentistry (1964-1970), Division of Stomatology, Columbia Univ. School of Dental & Oral Surgery

International President (1993-1999), International College of Cranio-Mandibular Orthopedics

Editorial Board of The Journal of Craniomandibular Practice (1993-96) (2000-03) (2007-present)

Co-chairman of the American Alliance of TMD Organizations (2000-4 )
Guest Consultant to U.S. FDA Dental Advisory Panel 1997
Medical Staff Appointment as Consultant: South Nassau Communities Hospital, Oceanside, NY
Medical Staff Appointment as Consultant: Manhattan Eye, Ear & Throat Hospital, New York, NY


Barry belongs to the follwing distinguished professional organizations:
American Dental Association
The New York State Dental Association
Nassau County & New York County Dental Societies
International College of Cranio-Mandibular Orthopedics
American Equilibration Society
American Academy of Pain Management
Alpha Omega Dental Fraternity

FELLOWSHIPS AND AWARDS

Fellow of the American College of Dentists (FACD)
Fellow of the International College of Dentists (FICD)
Fellow of the International College of Cranio-Mandibular Orthopedics
Mastership International College of Cranio-Mandibular Orthopedics
Diplomate of the American Academy of Pain Management


DR COOPER HAS BEEN A LIFELONG RESEARCHER AND HAS PUBLISHED THE FOLLOWING SCIENTIFIC PUBLICATIONS


Cooper, B. et al: Myofacial Pain Dysfunction: Analysis of 476 Patients. Laryngoscope: Oct 1986, 96:1099-1106. Presented at the Eastern Section of the American Laryngological, Rhinological and Otological Society, January 1986 (Phila., PA) American Equilibration Society Compendium 21:155-162, 1988
Cooper, B. and Rabuzzi, D.: Myofacial Pain Dysfunction Syndrome: A Clinical Study of Asymptomatic Subjects: Laryngoscope, 1984, 94(1). Presented at the Eastern Section Meeting of the American Laryngological, Rhinological, and Otological Society, January 1983 (New York, NY)
Cooper, B. and Mattucci, K.: Myofacial Pain Dysfunction: A Clinical Examination Procedure. International Surgery, 1985, 70:165-9.
Cooper, B.: Myofacial Pain Dysfunction: Cause, Clinical Appearance, Current Therapy. Primary ENT, Fall 1987 3(3):2-7. Reprinted in Compendium Vol 21, American Equilibration Society 1988, p.57-62
Cooper,B.: Craniomandibular Diseases. in Essentials of Otolaryngology, 3rd edition, eds. Lucente, F. and Sobel, S. New York, Raven Press 1993
Cooper, B. and Lucente F., eds. Management of Facial, Head and Neck Pain, Philadelphia: W.B.Saunders Company, April 1989
Cooper, B.C.: Craniomandibular Disorders, In: Cooper, B. and Lucente F., eds. Management of Facial, Head & Neck Pain, Phila.: W.B.Saunders Co., April 1989
Cooper, B.C.: Intraoral Pain, In: Cooper, B. and Lucente F., eds. Management of Facial, Head & Neck Pain, Philadelphia: W.B.Saunders Company, April 1989
Cooper, B.: Orofacial Development and Nasal Obstruction. in Otolaryngologic Clinics of North America (Nasal Obstruction issue), Kimmelman, C. ed., Philadelphia, W.B.Saunders Company, April 1989
Lunn,R., Cooper, B., Coy, R., et.al. White Paper of the Committee on Principles, Concepts and Procedures, Management of Craniomandibular Diseases. American Equilibration Society-Compendium, 20:177-237,1987
Cooper, B.: Guest Editorial. Journal of Craniomandibular Practice July 1988.
Cooper, B.: Myofacial Pain Dysfunction: A Case Report. Journal of Craniomandibular Practice 6: (4) 346-351, October 1988
Cooper, B.: Letter. Journal of Prosthetic Dentistry .61 (3):388-390, 1989
Cooper, B. and Cooper, D.: Multidisciplinary approach to the management of facial, head and neck pain. Presented at the Sixth Annual Convocation of the International College of Cranio-Mandibular Orthopedics, Florence, Italy April 1989. Pathophysiology of Head and Neck Musculoskeletal Disorders, Frontiers of Oral Physiology Volume 7, Bergamini,M. and Prayer Galletti, S. eds, Basil, Karger 1990, 76-82
Thomas, M. and Cooper, B.: Recognition of Craniomandibular Disorders. New York State Dental Journal 55(10)26-28, 1989
Cooper, B.: Neuromuscular Occlusion: Concept and Application. New York State Dental Journal 56:(4) 24-28, 1990
Cooper, B. and Cooper, D.: Electromyography of masticatory muscles in craniomandibular disorders. Presented at the American Laryngological, Rhinological and Otological Society, Palm Beach, FL, May 1990 Laryngoscope, 101:(2) 150-157, 1991.
Cooper, B. and Cooper D.: Multidisciplinary Approach to the Management of Facial Head and Neck Pain. The Journal of Prosthetic Dentistry 66(1). In Coy, R.E ed Anthology of Craniomandibular Orthopedics, Seattle, International College of Cranio-Manidibular Orthopedics, Vol.3.
Cooper, B.: Recognition and Management of Craniomandibular Disorders. in Otolaryngologic Clinics of North America (Otolaryngologic Office Evaluation and Management issue), Kimmelman, C.P. ed., Philadelphia, W.B.Saunders Company, 25(4) 867-887, August 1992
Cooper, B.: Electromyography of Masticatory Muscles in Craniomandibular Disorders. Presented at the 7th Convocation of the International College of Craniomandibular Orthopedics and the 5th Annual Congress of the Japan Association of Cranio-Mandibular Orthopedics, September 1991 (Osaka, Japan) in Coy, R.E ed Anthology of Craniomandibular Orthopedics, Seattle International College of Cranio-Mandibular Orthopedics, 2:127-144, 1992. In American Equilibration Society Compendium, 25: 70-77, Chicago, 1992
Cooper, B.C. Cooper, D.L.: Differentialdiagnostik bei Gesichts,- Kopf- und Nackenschmerzen. Philip Journal Vol 10 p337-344, July/August 1993 (in German)
Moses, A.J. & Cooper, B.C.: Understanding Temporomandibular Disorders and Whiplash. 2 part article CLAIMS July and September 1993
Cooper, B.C., Cooper, D.L.: Recognizing Otolaryngologic Symptoms in Patients with Temporomandibular Disorders. The Journal of Craniomandibular Practice: 11(4)260-267, October 1993. Presented at the 8th International Congress of the International College of Cranio-Mandibular Orthopedics. October 10, 1993 Banff, Alberta, Canada. In Coy, R.E ed Anthology of Craniomandibular Orthopedics, Seattle International College of Craniomandibular Orthopedics, Vol.3 , 1994
Cooper, B.C.: Objective Documentation of Post-Traumatic Craniomandibular (TMJ) Disorders. Trial Lawyers Quarterly, N.Y.State Trial Lawyers Institute., Vol.24, No.4 Summer 1994, p. 12-15
Cooper, B.C.: The Role of Bioelectronic Instruments in the Management of TMD. New York State Dental Journal, 61 (9) 48-53,November 1995
Cooper, B.C.: Who represents the TMD practitioner, Guest Editorial, The Journal of Craniomandibular Practice 14 (4) 251-253, 1996
Cooper, B.C.: Chronic Pain and Temporomandibular Disorders, in A Practical Approach to Pain Management, Lefkowitz, M. and Lebovits, A., eds. Little, Brown and Co. Boston, New York, Toronto, London, 1996, Chapter 28, 248-254.
Cooper, B.C.: Intraoral Pain, in A Practical Approach to Pain Management, Lefkowitz, M. and Lebovits, A., eds. Little, Brown and Co. Boston, New York, Toronto, London, 1996, Chapter 30, 259-264
Cooper, B.C. TMJ , in Lawyers' Guide to Medical Proof, Chapter 1106, Matthew Bender Publisher, October 1996
Cooper, B.C.: The Role of Bioelectronic Instrumentation in Documenting and Managing Temporomandibular Disorders. JADA 127 (11) 1611-1614, 1996
Cooper, B.C.: The Role of Bioelectronic Instrumentation in the Documentation and Management of Temporomandibular Disorders. Oral Surgery, Oral Pathology, Oral Medicine, Oral Radiology and Endodontics, Mosby- Yearbook, Inc. 83 (1) 91-100, 1997
Cooper, B.C.: Temporomandibular Disorders, Healthline, December 1997
Cooper, B.C.: The Role of Bioelectronic Instrumentation in the Management of TMD, Dentistry Today, 17 (7) 92-97, July 1998
Cooper, B.C.: Scientific Rationale for Biomedical Instrumentation. Neuromuscular Dentistry-The Next Millennium, Anthology V, D. Hickman,ed., The International College of Cranio-Mandibular Orthopedics, Seattle, WA 11-32, 1999
Cooper, B.C.: Temporomandibular Disorders Module, Otolaryngology National Resident Curriculum, Amer. Acad. of Otolaryngology, Head & Neck Surgery Foundation, November 2002, Revised 2007.
Cooper, B.C.: The Role of Bioelectronic Instruments in the Management of TMD. New York State Dental Journal, 61 (9) 48-53, November 1995
Cooper, B.C.: Parameters of an Optimal Physiological State of the Masticatory System: The Results of a Survey of Practitioners Using Computerized Measurement Devices. The Journal of Craniomandibular Practice, 22 (3), 220-233 July 2004
Cooper, B.C.: Dental Records Chapter, Medical Legal Aspects of Medical Records, Iyer Levin & Shea Editors, Lawyers & Judges Publishing Company, Fall 2005.
Cooper, B.C. and Kleinberg I.: Examination of a large patient population for presence of symptoms and signs of temporomandibular disorders. The Journal of Craniomandibular Practice 2007; 25 (2): 114-126.
Cooper, B.C. and Kleinberg I.: Establishment of a Temporomandibular Physiological State with Neuromuscular Orthosis Treatment Affects Reduction of TMD Symptoms in 313 Patients. . The Journal of Craniomandibular Practice April 2008; 26(2): 104-117
Cooper,B.C and Kleinberg, I: Relationship of Temporomandibular Disorders to Muscle Tension-Type Headaches and a Neuromuscular Orthosis Approach to Treatment, The Journal of Craniomandibular Practice, April 2009; 27 (2): 101-108


SCIENTIFIC PRESENTATIONS

Cooper, B. and Mattucci, K.: Myofacial Pain Dysfunction in Children and Adolescents. Presented at the Eastern Section Meeting of the American Laryngological, Rhinological, and Otological Society, January 1985 (Syraúcuse, NY).
Cooper, B C: Otolaryngologic Implications of Myofacial Pain Dysfunction. Presented at the 4th Convocation of the International College of Cranio-Mandibular Orthopedics 1985 (Kyoto, Japan)
Cooper, B C, et al: Recovering Lost Vertical Dimension of the Face Due to Occlusal Position. Presented at the Eastern Section of the American Academy of Facial Plastic and Reconstructive Surgery, January 1987 (Boston, Mass) and at the 5th Convocation of the International College of Craniomandibular Orthopedics, Honolulu, Hawaii, March 1987
Cooper, B C : Neuromuscular Concepts and the Utilization of Bioelectronics in Prosthetic Treatment. Presented at the 6th International Meeting of the College National D'Occlusodontologie March 1989 (Paris, France)
Cooper, B C: Orofacial Development and Nasal Obstruction. Presented to the Department of Otolaryngology of Mt. Sinai Medical College, New York, Dec. 1989
Cooper, B C: Neuromuscular Occlusion incorporated into everyday dental practice. Presented at the 66th Annual Greater New York Dental Meeting, Nov. 1990
Cooper, B., Cooper, D. and Lucente, F.: The importance of recognizing Myofacial Pain Dysfunction in the otolaryngologic population. Presented at the Meeting of the American Laryngological, Rhinological and Otologiúcal Society, February 2, 1991
Cooper, B C: The use of electronic data to determine Rest Position of the Mandible and the Neuromuscular Occlusal Position. Presented at the 7th Convocation of the International College of Craniomandibular Orthopedics & 5th Annual Congress of the Japan Assoc. of Cranio-Mandibular Orthopedics, Sept. 1991 (Osaka, Japan)
Cooper, B C: Neuromuscular Occlusion in Restorative Dentistry and the Treatment of Craniomandibular Disorders. Presented at the Graduate Prosthodontics Department of Temple University School of Dentistry, October 16, 1991
Cooper, B C: Neuromuscular Occlusion in Restorative Dentistry and the Treatment of Craniomandibular Disorders. Presented at the Second District Dental Society, Brooklyn, New York, October 25, 1991
Cooper, B C: Electromyography-Computerized Mandibular Scan-Sonography. Presented at the 9th Annual International Symposium on Clinical Management of Head, Facial Pain & TMJ Disorders. American Academy & Board of Head, Neck Facial Pain & TMJ Orthopedics. July 24, 1993 Anaheim, CA.
Cooper, B C & Duncan W E: Electronic Testing for TMJ Disorders. Presented at the Annual Conference of the American Academy of Pain Management. October 15, 1993 Knoxville, TN.
Cooper, B C: Neuromuscular Occlusion in Restorative Dentistry and in the Treatment of Temporomandibular Disorders. Presented at the Greater New York Dental Meeting. December 1, 1993 New York, NY
Cooper, B C: The Role of Electronic Measurement in the Documentation and Management of TMD. Presented at the International Workshop on TMDs and Related Pain Conditions. Sponsor: NIDR/NIH Baltimore, MD April 17-21, 1994
Cooper, B C: The Role of Electronic Instruments in the Management of Temporomandibular Disorders. Presented to the US Food and Drug Administration Dental Products Panel Hearing on "Muscle Monitoring Devices" October 13, 1994, Gaithersburg, MD
Cooper, B C: Otolaryngologic Symptoms in Patients with TMD and Their Treatment. Presented at the 40th Annual Meeting/Scientific Session of the American Equilibration Society, February 23, 1995, Chicago, Illinois.
Cooper, B C: Differential Diagnosis of Temporomandibular Disorders: Presented at the 40th Annual Meeting/Scientific Session of the American Equilibration Society, February 23, 1995, Chicago, Illinois.
Cooper, B C: Temporomandibular Disorders, Clinical Presentation, Cause and Current Therapy. Presented as a Grand Rounds Lecture, Department of Otolaryngology, Manhattan Eye, Ear & Throat Hospital, April 23, 1995, New York.
Cooper, B C: The Use of Bioelectronic Instrumentation in the Management of Temporomandibular Disorders (TMD) and Restorative Dentistry. Presented at the Greater Long Island Dental Meeting, April 27, 1995, Melville, New York.
Cooper, B C: The Use of Bioelectronic Instrumentation in the Management of Temporomandibular Disorders (TMD) and in Restorative Dentistry. Presented at the American Equilibration Society and Greek Prosthodontic Society Joint Satellite Program, July 1, 1995, Athens, Greece.
Cooper, B C: Otologic Symptoms in Patients with TMD and Their Treatment. Presented at the Ninth International Congress of The International College of Cranio-Mandibular Orthopedics, October 14, 1995, Toulouse, France.
Cooper, B C: Developing a TMD Treatment Protocol. Presented at the Ninth Annual Bernard Jankelson Memorial Forum of the International College of Cranio-Mandibular Orthopedics, November 18, 1995 Phoenix, Arizona.
Cooper, B C: The Use of Electronic Instrumentation in TMD Management. Presented at the Greater New York Dental Meeting. November 25, 1995, New York, NY
Cooper, B C: The Role of Bioelectronic Instrumentation in the Documentation and Management of Temporomandibular Disorders. Presented at the NIDR/NIH Technology Assessment Conference on the Management of Temporomandibular Disorders, National Institutes of Health, Bethesda, MD April 29, 1996
Cooper, B C :The ADA Seal Program for Measurement Devices used as diagnostic aids in TMD, Presented to ADA Council on Scientific Affairs, Chicago Sept. 19, 1996
Cooper, B C: Introduction of The ICCMO Protocol for the Management of Temporomandibular Disorders. Presentation at the 10th Annual Bernard Jankelson Forum of the American Section of the International College of Cranio-Mandibular Orthopedics, Arlington Va. October 18, 1996
Cooper, B C: Otolaryngologic Symptoms in a TMD Population, Neuromuscular Occlusion in Restorative Dentistry and in the management of TMD, The Role of bioelectronic instruments in the documentation and management of TMD, Presented as the Lectio Magistralis at the joint meeting of the Academia Italiana di Kinesiografia ed Elettromiografia Cranio Mandibolare & Italian section of The International College of Cranio-Mandibular Orthopedics, Alessandria, Italy. November 17, 1996
Cooper, B C: The Role of Neuromuscular Occlusion in the Treatment of Temporomandibular Disorders: Presented at the 42nd Annual Meeting/Scientific Session of the American Equilibration Society, Feb. 20, 1997, Chicago, Illinois
Cooper, B C: Neuromuscular Occlusion and Bioelectronic Instrumentation in the Treatment of Temporomandibular Disorders: Presented at the 10th International Congress of The International College of Cranio-Mandibular Orthopedics, Osaka, Japan April 13, 1997
Cooper, B C: Restoring the Compromised Dentition: Through Neuromuscular Occlusion, Presented at Cordent Trust Conference, London,England, June 6-7, 1997
Cooper, B C: The Role of Bioelectronic Measurement and Neuromuscular Occlusion in the Management of Temporomandibular Disorders: Presented at the Greater New York Dental Meeting, New York, NY, November 30, 1997.
Cooper, B C: Temporomandibular Disorders: Concepts and Current Management, Presented at the Department of Otolaryngology Manhattan Eye, Ear & Throat Hospital, New York, December 3, 1998. Presented at the Department of Otolaryngology SUNY Downstate College of Medicine, September 26, 2002.
Cooper, B C: Temporomandibular Disorders and Orofacial Pain: Clinical and Research Findings, Presented: Eastern Pain Assoc. Conference, NY, Dec.11, 1998
Cooper, B C: Temporomandibular Disorders and Electronic Instrumentation. Presented at the American College of Dentists Lecture Program Series at:
Columbia Univ. School of Dental & Oral Surgery, New York, February 10, 1999.
State University of NY, Stony Brook, School of Dental Medicine, March 25, 1999.
New York University School of Dentistry, April 14, 1999.
Cooper, B C: Neuromuscular Occlusion & Bioelectronic Instruments in TMD Management & in Restorative Dentistry. Greater NY Dental Meeting, Nov. 2000.
Cooper, B C: Integrating Neuromuscular Occlusion into a Dental Practice. 15th Annual Bernard Jankelson Forum of the American Section of the International College of CranioMandibular Orthopedics, Vancouver, BC, November 2, 2002.
Cooper, B C: Temporomandibular Disorders: Current Concepts and Management, Presented at the Department of Otolaryngology SUNY Downstate College of Medicine, July 8, 2004.
Cooper, B C: Temporomandibular Disorders: Cause, Clinical Presentation and Conservative Treatment. Presented at the Department of Otorhinolaryngology, New York Presbyterian Hospital, Weill Medical College of Cornell University, August 5, 2004.
Cooper, B C: Successful Integration of Neuromuscular Occlusion into the General Practice, Myotronics, Inc., 38th Anniversity Seminar, Seattle, WA, August 16, 2004.
Cooper, B C: Documenting Efficacy of Neuromuscular Dentistry, International College of Craniomandibular Orthopedics, 17th Annual Jankelson Memorial Lecture Forum, Newport Beach, CA, October 16, 2004.
Cooper, B C: Neuromuscular Occlusion in TMD and Restorative Dentistry, Greater New York Dental Meeting, New York, NY, November 30, 2004.
Cooper, B C,: Quantitive Valuation of TMD Patients from Basic Research to Clinical Application, Advances in Oral Physiopathology, University of Turin, Congresso Internazionale, Turin, Italy, December 11, 2004.
Cooper, B: Neuromuscular Occlusion in Restorative Dentistry & The Treatment of TMD. Presented at the Nassau County Dental Society, April 5, 2006
Cooper, B: Temporomandibular Disorders: Concepts and Current Management. Presented at the Department of Otolaryngology of New York Eye & Ear Infirmary, New York Medical College, April 19, 2006
Cooper, B C: Integrating Neuromuscular Occlusion into a Dental Practice. 18th Annual Bernard Jankelson Forum of the American Section of the International College of CranioMandibular Orthopedics, Orlando, FL, October 27, 2006.
Cooper, B C: Neuromuscular Occlusion in TMD and Restorative Dentistry. Greater New York Dental Meeting, New York, NY, November 26, 2006.
Cooper, B C: Neuromuscular Occlusion Workshop: Neuromuscular Dentistry TMJ/TMD & Restorative Dentistry. The Center for Occlusal Studies, Parkersburg, WV., March 8-10, 2007.
Cooper, B C: Neuromuscular Occlusion in TMD and Restorative Dentistry, AGD College Station, Texas, November 2, 2007.
Cooper, B C: Examination of a large patient population for presence of symptoms and signs considered to characterize temporomandibular disorders, and Integrating Neuromuscular Dentistry into a Dental Practice Change. 14th International Congress of The College of CranioMandibular Orthopedics, Vicenza, Italy, November 16-18, 2007.
Cooper, BC: Integrating Neuromuscular Dentistry (NMD) Into a Dental Practice. Myotronics 42nd Anniversary Seminar, Seattle, WA July 19,2008
Cooper, B.C: Introduction to Neuromuscular Dentistry. Presentation at the 20th Annual Bernard Jankelson Memorial Forum of the American Section of the International College of Cranio-Mandibular Orthopedics, Denver, CO September 25, 2008
Cooper,B.C: Temporomandibular Disorders, Grand Rounds Lecture Department of Family Practice, South Nassau Communities Hospital, Oceanside, NY, December 19, 2008

Are there tmj specialists? Is neuromuscular dentistry a specialty? Are neuromuscular Dentists Headache Specialists?

The answer to all of the above is no. There is no specialty in treatmrnt of TMJ disorders (TMD). Specialties are decided by the American Dental Society and individual state laws. There are however many trained Neuromuscular Dentists who devote a major part of their practice to treating TMJ patients, chronic pain patients, headache patients etc.

Neuromuscular Dentistry is unique in that it uses biomedical instrumentation to aid in the diagnosis and treatment of TMJ disorders, TMD, Myofascial pain (MPD) and referred head and neck pain.

Should there be a TMJ or orofcial pain specialty? Absolutely not!

There are often many approaches to dealing with a chronic pain problem involving the teeth and jaws. Research has shown that different approaches can be successful. Creation of a specialty is almost certain to prevent patients from a full choice of therapeutic options. There are many educational and scientific societies dedicated to treating chronic pain. The Alliance of TMD organizations has taken a stand against specialty.

I firmly believe that neuromuscular dentistry is the best method for treating most fuctional disorders of the masticatory system including MPD, TMJ, TMD and occlusion. I will be happy to respond to specific questions on this blog why I believe it is the best approach.

I am a Fellow of ICCMO the group representing Neuromuscular Dentistry but I also go to yearly meetings of the AES or American Equilibration society. I belong to the American Academy of craniofaciall pain and have attended many meetings over the years. I also belong to IACA, the international academy of comprehensive esthetics that combines function and esthetics and I am a Diplomate of the academy of pain management.

Many of these groups overlap and share common goals and ideas and there are also major disagreements between groups as to what is the best treatment.

Almost universally they show great success in treatment.