Raman Smiles Blog

Locating Prabu Point ....safely!

There have been some instances that the myotrode has been incorrectly placed right over the SCM at the level of Carotid sinus.  This is potentially dangerous.

When I looked into it, this occurence is related to HOW the Prabu Point.

One way to locate SCM is to have the patient turn the head to the side. But if the Prabu Point is located when the head is turned, when the patient turns the head straight, the SCM rolls...as it should..and roll under the previously located point.  This turned out to be culprit.

The proper way, as I had described in my ICCMO Masterhip thesis....is to have the patient continue to look straight.  But offer resistance to the head to turn against. This makes the SCM stand up...even in heavy people...but once the Prabu Point is located...in the middle 1/3 of the Posterior Cervical triangle.. the SCM does not change location.

I have attached a Power Point to illustrate this here.

Download locating_prabu_point.ppt

Dental health affects fertility

The connection between dental health and overall health....the "Oral systemic link" is widely recognized.  Most of the studies related to periodontal ( gum support) disease and heart disease, stroke, diabetes and low birth weight babies.  It makes sense to expect that infection in one area of the body is bound to affect other areas.  But this new study has an interesting twist.

Male infertility is often connected to connected to chronic bacterial infection of the epididymis.  This is the structure that "stores" semen.  This study from Germany showed a direct connection between male sterility and dental infections.  An abstract with the references is below.

They only studied those that were resistant to antiobiotic therapy.  I wonder if the results would be even better if all of the sterile subjects were included in the study.

One more reason to make dental health and its maintenance a high priority!

 

1: Andrologia. 1993 May-Jun;25(3):159-62. Links

Bacterial foci in the teeth, oral cavity, and jaw--secondary effects (remote action) of bacterial colonies with respect to bacteriospermia and subfertility in males.

Bieniek KW, Riedel HH.

Department of Obstetrics and Gynecology, University of Halle-Wittenberg, Germany.

Bacteriospermia requiring medical treatment were diagnosed in more than 70% of the subfertile patients who had since 1988 attended the gynecological clinic at the RWTH hospital in Aachen. In 23% of all cases specific treatment with antibiotics did not reduce the concentrations of bacteria in sperma. Thirty-six patients with bacteriospermia resistant to antibiotic therapy were then subjected to dental examination. A high incidence of potential dental foci was found in all patients. In a test group of 18 patients these sources of potential infection were eliminated. Between dental operations and therapy swabs were taken to determine bacterial levels and bacteriological composition. It could be demonstrated that the bacterial spectrum of the intraoral samples was almost identical with the spermiograms. Six months following completion of dental treatment a further spermiogram analysis was carried out. In the test group about two thirds of the spermiograms proved sterile. Spermatological parameters, such as motility, density and morphology, had also clearly improved. In the control group the findings of the spermiogram remained poor. This study indicates that a direct causal relationship exists between bacterial colonies (dental foci) and therapy-resistant bacteriospermia which probably leads to subfertility.

NM Dentistry helping vocalists - success stories

 

 

After, Dr. Sahag Mahseredjian recently raised the question:   Could NM Dentistry help Vocalists, opera and other professional singers? .....there were a couple of actual success stories reported. 

 

Another friend, Dr. Ritchey from Oklahoma, shared a case where he treated a music student who is in operatic training.  Her main complaint was pain and stiffness in her neck and jaw. During his Q&A conversation with her she mentioned that her voice coach was always telling her to relax her throat and jaws.  Truth was, she couldn't, even though she did everything her coach said to do.

After he delivered her a NM orthotic, she came back a week later  pain-free and, lo and behold, grinning from ear-to-ear.  She can relax her throat and reach notes she had not been able to reach. Her coach was dumbfounded.  She said she sang better than she ever had in her life.  This was 2 yrs ago and she continues to benefit from pain relief and the relaxation of her head and neck muscles.  She is convinced that the orthotic was the thing that "unlocked" her voice, and told everybody about it.

 

Another friend from Australia, Dr. Craig Duval shared this story:  His mum is a music specialist and a singing teacher. She teaches for about 22 -24 hours a week.  She also does a lot with her 3 choirs. He placed her fixed orthotic 9 weeks ago in preparation for a FM rehab.

 

 She now has more freedom of movement in her neck (even though she didn’t know it was restricted before). She has also noticed a slight change in her posture (less rounded shouldered, ie what we typically call forward head posture but what is really forward neck posture).  She’s been getting mild headaches every cycle for years and was mostly fine without pain killers, but has now had 2 cycles without headaches. 

 

Her holidays started last week and usually by the time holidays start she really looks forward to it to give her throat a rest and allow some recovery time, however, this holiday she commented that it feels like she’s only at the start of term!

 

So, the potential is really unlimited in allowing people to be at their best when you have their bite in it’s ideal – neuromuscularly balanced position

 

 

 

Could NM Dentistry help Vocalists, opera and other professional singers?

A good friend of mine from Canada, Dr. Sahag Mahseredjian raised this question in an e-mail.  I have edited and paraphrased the information below.  Many professional vocalists impose very heavy demands on the mandible (lower jaw).  When a singer performs vocal exercises for many hours, the jaw movements border upon the extremes of its physiologic range.  Lower jaw motion is energized by the muscles that link the mandible above to the bones of the face and cranium, and below to the neck, including the hyoid bone, clavicle (collar bone) and sternum (breast bone).

 

Healthy mandibular movement for effective vocalization requires a neurophysiologic integration of all of the muscles and bones involved in carrying out this function. If the jaw is not in NM position, head & neck muscles are usually in a hypertonic (tight) state.  This may affect their performance.

 

A common condition affecting professional vocalists is cranio-mandibular-cervical muscular dysfunction resulting from sprain of the muscles connecting the mandible to the head and neck. This dysfunction adversely affects the quality of the voice and also may cause head, facial and ear pains. The major muscles involved in voice production are strongly influenced by mandibular position.  So, a craniomandibular-cervical muscular dysfunction can result in hoarseness and chronic voice irritation which interferes with the ability of the vocalist to produce sounds of good quality and high amplitude.

 

An explanation of the anatomy of this area is below:

The trachea is the main trunk of a system of tubes by which air passes to and from the lungs. The respiratory system which includes the lungs functions to inhale and exhale air through the trachea.

 

The larynx is the modified upper section of the trachea and contains the vocal cords. These include a pair of vocal folds that when drawn taut and subjected to a flow of breath, then vibrate to produce the sounds of the voice. In the context of the human voice, resonance refers to the quality imparted to sound vibrations originating in the larynx by resonator chambers formed by the oral and nasal cavities. The power or amplitude of the voice depends on respiration.  Hence the breath control training for singers that emphasizes deep diaphragmatic breathing.

 

The larynx is composed of four principal cartilages: the thyroid, the cricoid, the arytenoid and the epiglottis. These cartilages are controlled by three primary groups of muscles. When contracted, the cricothyroid muscle brings the cricoid and thyroid cartilages together, thereby stretching the vocal cords to control the pitch of the vibrations produced thereby. The tension on the vocal cords is primarily controlled by the thyro-arytenoid muscle, while three sets of arytenoid muscles are involved with vocal cord adduction.

 

The proper balance of the muscles of the larynx is essential to effective vocalization. The laryngeal mechanism is a precision instrument requiring critical muscular tensions and cartilage positions to produce optimum sounds.

 

The larynx is suspended from the hyoid bone disposed in the throat between the thyroid cartilage and the roof of the tongue. The hyoid bone is linked by muscles to the mandible or lower jaw. The tension on these muscles is a function of the position of the mandible, and has a strong influence on the behavior of the larynx.   

 

A Neuromuscular Orthotic exploits the relationship between mandible position and voice production to significantly improve the ability of a vocalist to produce sounds of fine quality and high amplitude.

 

A Poem from Lisa

When I had just a general dentistry practice for years, I used to work very hard to do a great root canal treatment on a maxillary second molar, for example.  But I never received a "Thank you" note .  "Thank you" notes are not so uncommon once I decided on a TMD / NMD practice and help people with head aches, jaw pain, ear pain and other symptoms of TMD..

 But a poem?  This is a first for me ! 

As a background, Lisa, who is 46 years old, had 4 bicuspid extraction / retraction orthodontics as a teenager (surprise, surprise!). She has suffered with “TMJ” since the 80’s which got much worse in the early 90’s when she was in an auto accident. So she has suffered with unrelenting daily headaches and jaw pain for a long time.  She is doing great with a lower fixed orthotic for 3 months now and is ready for Phase 2.

Amy is my concierge and Melissa is my Care Coordinator (clinical assistant) and Dave is Lisa’s husband.  You have to forgive the Wizard of Oz reference….I live in Kansas City after all <VBG>.

 Download lisasnow_poem.pdf

A poem affects us in a different way from prose. I was quite touched to receive this clear out of the blue.

Dual arch temp technique

I have shared this technique several times on the LVI Forum.

I am posting it here for your convenience.  Open the Powerpoint as "Read Only".  You don't need a password for it.  It is put in so that it may not be modified.

Let me know if you have any questions.

Jaw bone connected to the head bone...head bone connected to the neck bone.....

Most people remember the children's song for teaching human skeletal bones that goes something like........

The foot bone connected to the leg bone, The leg bone connected to the knee bone, The knee bone connected to the thigh bone, The thigh bone connected to ...etc. Yet... dentists have traditionally looked at the manbible as though it operates in isolation.  Not much attention is paid to the posture of the neck or rest of the body.  In reality, the lower jaw and head works together as a 'functioning unit' when chewing and moving.  There have been a number of studies, especially in Physical Therapy literature, about the connection between jaw/ bite relation and neck posture. Poor neck posture has an important role in causation of headaches as well. Neuro Muscular dentists understand this connection and recognize the need for correcting neck posture along with jaw alignment for stability.  Hence the development of a new method for relaxing the neck muscles, discussed in an earlier post in this blog. The case study here is that of a physician who had suffered with headaches and jaw pain for many years.  Despite several therapy attempts including orthodontics twice, the problem was not solved.  Once we determined the NM bite position with the optimal jaw and neck position, a fixed orthotic was placed on his lower teeth. This is just 2 weeks later.  See the change for yourself.  The guest reports 90% improvement of the symptoms!  It is easy to see why! This image shows the "normal" alignment of the head.  The ear hole (External Auditory Meatus) should line up perpendicularly above the shoulder. This image is before and after orthotic on this guest. This improved jaw alignment is also conducive to improved Airway!  Sleep Breathing Disorders, including Sleep Apnea is a huge problem.  So correcting the jaw alignement often helps airway also. How about the change in profile?  Look at the lower third of the face.  It looks more proportionate...and younger! Correcting the jaw alignment has profound improving effects.  Jaw bone connected to the head bone....head bone connected to the neck bone...neck bone connected to the back bone......<G>.

Is it "Typical" TMJ? Progress (Continued)

K.H. is now wearing  a fixed orthotic to correctly align her lower jaw.

The progress report at 4 weeks of orthotic therapy showing 95% improvement and her comments are reproduced below.  This is a “Comfort Scale” instead of the usual “Pain Scale”.  So a 10 is perfect and 0 is worst.

Once the mandible is optimally aligned, the rest of the musculature adapt which it turn affects the mandibular position.  Fine tuning this over 3 months will get us ready of the Phase 2 Stabilization.  There are many options at that point.  Most likely in K.H.’s case, I will start with Neuromuscular Orthodontics and possibly finish with porcelain restorations.

This case illustrates three points. 

1.  Most TMD cases don’t present with “typical TMJ” symptoms. 

2.  Seemingly unrelated musculoskeletal symptoms and referred pain could be due to poor mandibular alignment

3.  With the Neuromuscular LVI protocol the “difficult” cases often resolve very quickly.

Is it "Typical" TMJ?

This is the story of K.H. who is a Kansas City, MO Police detective.  She was referred to us by her family dentist for evaluation.  K.H. is a very physically fit 30+ year old that had suffered with a variety of symptoms, none of which were “typical TMJ” symptoms.  Her primary complaint at her dentist’s office was ongoing tooth aches of unknown etiology.  The dentist had conscientiously checked the teeth repeatedly and found no cause for the pain.  To his credit, no treatment was provided to these teeth since he could not find an objective reason for the pain.  I have seen many cases where endodontic treatment and even extractions were done due to reported severe tooth pain.

Despite wearing the night guard that her dentist had made for her for 3 years, the symptoms were gradually worsening.  Our initial conversation brought to light many other symptoms such as ear pain, tinnitus, neck pain, shoulder pain, back pain, tingling down the arm, fatigue etc. that she has endured for many years.  K.H. had attributed much of this to her stressful job.  No one realized that there may be a connection to TMD.  Parts of her questionnaire are reproduced here.

  A battery of tests including detailed jaw computer scans, i-CAT CT scan imaging of the joints and other records revealed the discrepancy between the current occlusion and the optimal jaw alignment where the muscles would be unstrained.  K.H. now has a fixed LVI orthotic on her lower arch precisely made to align her mandible. 

Her progress will be reported on my next blog...entitled  "Is it "Typical" TMJ? Progress"

What is "typical TMJ"?

What is a typical “TMJ”?

It is common for a patient to come to our office who has had various pain or dysfunction symptoms for years.   Often, the patient has spent time and money unsuccessfully pursuing alternate therapies. At times, it is because the patient had been told that she does not have “TMJ” since it is not “typical”. 

So it begs the question what is a “typical TMJ”? 

What were we taught in dental school? 

1.  Clicking joints are fairly common and do not need any intervention.   

2.  “TMJ” is self limiting and “settles” down with time. 

3.  “TMJ” is primarily a “psycho social disorder” that is stress-induced. 

4.  Pain or discomfort in the TM joints or the joints locking open or closed constituted typical “TMJ” symptoms. 

The conservative therapy would be occlusal splints or bite guards along with soft diet and perhaps some muscle relaxing medications.  That would help many patients to get some symptom relief. If that does not help, then the next step is referral to a maxillo-facial surgeon for joint or jaw surgery.

If we look at this as a “joint” problem, then when joint symptoms (such as pain or strain in the TM Joints, clicking, popping or grinding of the TM joints) appear, it is “typical TMJ”.  Our dental education placed the emphasis on joint position when it comes to occlusion. 

Let me use an analogy to illustrate another way to look at this.

 

I am sure you can think of a door that does not quite shut right, where the door runs into the door jamb first.  How do you shut the door to keep the cold air out?  Some would answer, “slam it”, or “lift the door and push it” or some other answer.  If that is done thousands of times, what would happen to the door and jamb where they meet first?  Would there be damage to the paint or wood at this place?  What would happen to the hinges over time?  Would there be some strain at the hinges? They may creak, wear out or fall apart.  If that happens, would the solution be to just put a new hinge in?  If so, how long would it last, before the new hinges wear out as well?  Unless the underlying cause of the problem is addressed, it may not last.

The way the door swings freely before running into the jamb is analogous to the neuromuscular trajectory of the mandible.  The wear in the door (mandibular incisors) and door jamb (maxillary incisors) is something all of us commonly see.  Correcting the door and jamb so they align readily without straining the hinges, is analogous to a Neuromuscular bite correction. 

What are missing in this analogy are muscles and nerves.  The mandible (lower jaw) is much more complex than a hinged door.  It is controlled by the muscles of mastication which includes neck muscles. 

Nerves send the commands to the muscles and also sense their position or strain.  This could result in a number of symptoms including headaches, neck aches, tingling down the arms, ear pain, ear congestion, tinnitus, pain referred to teeth etc. 90% of ALL pain is muscular in origin.  But it still may not be “typical TMJ”.

One way to reduce the tension on the hinges is to put a door prop and not allow the door to close.  This is similar to a bite guard or an NTI device.  But doors are meant to close and teeth need to occlude- fit together - for chewing function. 

It is, of course, the patient that chooses whether to correct the jaw alignment or just lessen the strain on the masticatory system, or take medications to mask the syptoms or do nothing at all. 

As long as we have educated the patient about the consequences of each option including ‘doing nothing’, we can absolutely support any of the informed choices they make.  Ultimately the decison is theirs.