Raman Smiles Blog

Primum non nocere ("First, do no harm") Part 6

How do we KNOW that there is improvement with our therapy?  Of course, subjective reports are important.  But how do we know that it is simply not the case of a patient desperately hoping for an improvement that overstates the change?

Objective measures confirm or invalidate the subjective findings.

   

 TMJ CT sagittal view Pre-OP                                With Orthotic...confirming decompression

    

 

emg - muscle activity at rest on the left half and at light occlusion- gently touching teeth on right half

    

Muscle Activity while lightly touching on natural teeth Vs on orthotic shows much calmer muscles.

Primum non nocere ("First, do no harm") Part 5

This is the continuation of Sue's story.

Once the diagnostic tests revealed where the mandible SHOULD align, the next step is to make that change in a reversible way.  Remember!  Primum non nocere ("First, do no harm").  IF for some reason the patient does not get better, we need to make her no worse.  That means reversibility to the condition when she presented at our office.

Fixed LVI orthotic was placed on the mandible and fine tuned with the K7 instrumentation.  The progress is measured 3 ways:

a. Subjective reports

b. Objective tests - K7 scans of emg and mandibular movements and CT scans of the joints and cervical spine

c. Objective / Subjective:  Palpations of jaw and neck muscles and TM joints.  The pressure of palapation is consistent and objective.  But the patient's response is subjective.

The images of the orthotic are below:

    

This is her report two weeks later.  Immediately after delivery Sue had gone on a long planned vacation and just returned for this follow up visit. 

 

 

Primum non nocere ("First, do no harm") Part 4

This is the continuation of Sue's story.

My challenge was to diagnose very precisely where the jaw fits now (where there are symptoms) and where the jaw SHOULD fit if all the jaw / neck muscles are unstrained AND the jaw joints are in an optimal position as well.

Our Neuromuscular diagnostic protocol includes measuring emg's before and after these muscles are optimized.  The end result is the mounted casts aligned with the myobite taken at the end of these tests.  We KNOW that the muscles will be unstrained in this position because we measure these muscles when the natural teeth are occluding and when they are occluding on the myobite.  When we see that the muscles are much quieter with the myobite, it confirms the correctness of the bite relation.

 View from front showing a larger "gap" on her right side, where recent restorations were done.

    

The anterior posterior discrepancy would explain the many adjustments needed on her upper front teeth after veneers were done....and the pain since the mandible had to posteriorize to avoid this area from proprioception.  This explains the joint pain.

In the next post, we would show how this was corrected and the results.

Primum non nocere ("First, do no harm") Part 3

Sue suffered with these symptoms (listed below) for over 6 months. She had seen a family physician and a neurologist who had tried various medications, as is the norm.  Nothing helped.  She finally heeded the advice of a friend who was treated with NM orthotic.  So very skeptically, Sue came for an evaluation.

  This was her baseline form.  We choose to use a "comfort scale" instead of the usual "Pain scale".  So a Zero is the worst.  Her pain when chewing and pain the TM joints were Zero - meaning constant, severe pain.  All her other symptoms were in the "Severe" range, as can be seen above.

I will describe the treatment in the next post - Part 4

Who needs a seat belt? Part 2

It is common for the chronic TMD sufferers to have over stretched the ligaments of the TMJ.  This results in the joints being too loose.  When sleeping, the jaw often falls back and interfers with breathing.  There are studies that link bruxism ( clenching and grinding) to Sleep Disordered Breathing. 

Gilles Lavigne, a researcher in the Faculties of Dentistry and Medicine at Université de Montréal, explains that “the development of neurobiology has enabled us to better understand the structure of sleep in clenchers and to define bruxism clearly as one of many cyclic phenomena that are characteristic of sleep.” The researcher and his team at Sacré-Cœur hospital in Montréal have now gained international recognition for establishing criteria to identify nocturnal bruxism.

Many medications that are classified as Selective Serotonin Reuptake Inhibitors (SSRI) have been shown to induce clenching especially during sleep. 

Drugs in this class include (trade names in parentheses): (source: Wikipedia)

• citalopram (Celexa, Cipramil, Dalsan, Recital, Emocal, Sepram, Seropram)
• dapoxetine (no trade name yet; not yet approved by the FDA)
• escitalopram (Lexapro, Cipralex, Esertia)
• fluoxetine (Prozac, Fontex, Seromex, Seronil, Sarafem, Fluctin (EUR), Fluox (NZ), Depress (UZB))
• fluvoxamine (Luvox, Fevarin, Faverin, Dumyrox, Favoxil, Movox)
• paroxetine (Paxil, Seroxat, Sereupin, Aropax, Deroxat, Rexetin, Xetanor, Paroxat)
• sertraline (Zoloft, Lustral, Serlain)
• zimelidine (Zelmid, Normud)

These medicines are used so commonly for a long list of indications, this is definitely something to be aware of.

When I wear my seat belt before driving my car on the street, it does not show a lack of confidence in my driving ability.  There are other drivers on the road that may be impaired or inattentive.  There may be a mechanical problem such as a blown tire from a nail on the street.  So wearing a seat belt is a sensible thing to do.

If we prescribe a sleep appliance such as Somnomed MAS after finishing a Neuromuscular Reconstruction, it shows prudence.  Not a lack of belief in our ability.  Just like wearing a seat belt.

 

Who needs a seat belt? - Part 1

Neuromuscular dentistry is based on these fundamentals: 

• measured, objective data is fact; while all else is just opinion

• start with unstrained jaw and neck muscles that move the mandible

• allow the lower jaw to move through a trajectory which is determined by the simultaneous contraction of all of these unstrained muscles and optimal TM Joint conditions

• freedom of entry in to and exit from, a stable bite position

• address ascending posture factors with co-treatment from physical therpists and AO (Atlas Orthogonal) chiropractors

With this level of attention to muscles, posture and joints as well as micro occlusion of the bite, most of the usual reasons for breakage of restorations (crowns, veneers etc.) are successfully addressed.  As such the usual cause of breakage, interferences when chewing and bruxism is resolved to a great extent.

Should a NM dentist then prescribe a "seat belt" for his restored patients? If he or she gives a sleep appliance or night guard, after NM full mouth resotrative treatment, does it exhibit a lack of confidence in the priciples of Neuromuscular dentistry?

Let us look at this more closely in the next post!

Do they have to suffer?

I am continually amazed about the lack of information on the web about Neuromuscular dentistry as a real solution to TMD.

Amy ran into a blog site by this young woman who had suffered for half of her life with "TMJ".  Among other things, she had an NTI, splints, arthrocentesis...total nine (9) jaw surgeries in the last being Bilateral TMJoint replacement in Jun 2006.  This suffering, apparently, had taken a heavy toll on her personal life.  She has an extensive overview of TMJ, but evidently has not heard of NMD.  What a shame!

Here is the e-mail I sent her today.  I hope she would contact me back and have a dialogue...so that she can pass on the NMD solution to her audience.

Hello Stacy:

My wife, who was a TMJ / TMD sufferer, was surfing the web, when she ran across your blog.  She was fascinated to read your heart wrenching story and asked me to write to you.

You are a remarkable young woman to have gone through what all you have gone through...and trying to inform people about TMD.  My wife noticed no information about a non-surgical approach - called Neuromuscular dentistry -  that is extremely successful in treating folks that have suffered for years.  She herself has been pain free for many years since treatment. 

Every doctor, in my opinion, means well.  They all want to help their patients.  But in this area of Temporo Mandibular Dysfunction, as you probably found out, there are widely varying ideas about the nature of this problem.

Some believe that it is a psycho-social problem.  So the solution is counseling, bio-feedback etc.  It does work...some times.

Others believe that it is bio-chemical. For some unknown reason there is an imbalance of Serotonin levels.  So the solution is medications...such as Neurontin etc.  It does work....some times.  Or an imbalance of hormones...that need to be corrected.  It does work...some times.

Others believe that it is a parafunction of an unknown origin...and make a crutch...NTI device...to disable the clenching muscles.  It does work.....some times.

Others believe that it is the jaw joint not aligning properly into the socket.."Centric relation" of the joint.  So through manipulation of the jaw, "romancing the mandible", they would seat the joint carefully, and make splints or change the teeth get this joint alignment.  It does work...some times.

If it is the joint and the joint is popping, disc torn, then the solution might be to sew the disc in place.."plication surgery"....or cut off the condylar head .."condylectomy"...or in extreme cases..."artificial joints"...such as Christensen devices.  It does work...some times.

So what is the real nature of this condition called TMD or TMJ syndrome? This story may illustrate the true nature.

There were four blind men, that heard of this new animal at the local zoo and wanted to go find out what this animal is like.  The first one exclaimed, "this animal is so large, rough and wide..like a wall".  The next one yelled, "no, no, This animal is round and straight like a tree trunk".  The third one cried "I have no idea where you guys get that.  This animal is hard, smooth and comes to a point..like a spear". The fourth one declared, "You are all wrong...this animal is round, flexible and long...like a python".

If only the blind men could have opened their eyes and be able to see...they would have realized that it was an elephant!

By taking a view that there are many factors that lead to TMD, but correct the most important one...the muscles that move the jaw by precisely determining their most unstrained position, the biggest factor is corrected....along with correcting as many of the others as feasible, the cause of the pain is addressed.  So Pain relief once and for all instead of just Pain Management is achieved.

The link below tells the story of a woman that had a total of eight surgeries (four in each joint) and still had pain..and was planning on taking disability and quit her job as an R.N..  She was able to get lasting relief withoug another surgery or medications...and has been pain free for almost 2 years now.

http://healthyteethforlife.com/content/lsuccessstoriesdetail.cfm?key_id=18

http://www.midwestheadaches.com/content/mpfTMJPain.cfm

If this intrigues you, feel free to look through the following links. This is my life's work now to devote my energies to end the suffering of so many people that have suffered for so long.

http://www.midwestheadaches.com/

http://www.ramansmiles.typepad.com/

My hope is that you will give this information to your audience.  They don't have to suffer as you had endured for so many years.  There is a solution that addresses the cause and not the effect.

Feel free to contact me with any questions or comments.

PR