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

Primum non nocere ("First, do no harm") Part 2

This is a story of a nice lady that sought our help recently. 

Sue is a 40 something woman who wanted to improve her smile.  So her dentist provided aesthetic all ceramic crowns for the upper front teeth.   

               

She also had tooth colored crowns to restore some    of the back teeth with large amalgams.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sue had several bite adjustments to these restorations since it did not feel right.  The symptoms gradually progressed to the point of "debilitating".  She loved her work caring for mentally challenged people.  But she simply could not carry on, when she had constant pain that had worn her down.  The list of symptoms is long and they were present constantly. 

 

I will talk about these symptoms and what was done....in the next post:  Part 3

 

 

 

 

Primum non nocere ("First, do no harm") Part 1

Primum non nocere is a Latin phrase that means "First, do no harm."

While this is often erroneously attributed to Hippocrates, this maxim has nevertheless been a foundational principle of medical ethics for many years.  I believe that it equally applies to the practice of dentistry as well.

Cosmetic dentistry and orthodontics provide tangible benefits to patients.  A confident smile and improved self esteem greatly improve the quality of life of many.  But if the principles of physiology and function are violated there could be more harm caused than no treatment at all.  "First, do no harm."

This is by no means an indictment of all cosmetic or orthodontic services.  But it is a call for prudence and careful consideration of the patients that trust us as their dentist.

 

I will describe a case to illustrate this point in Part 2.

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!

Dual Arch Temporary technique

The Powerpoint did not get included in my post on this subject.  So here it is......

Download one_shot_temp_technique_pdf.pdf

Provisional technique for Onlay restorations

Bonded ceramic restorations are an excellent aesthetic option for preserving tooth structure.  But making a provisional (temporary) restoration presents some challenges.

I have been using this technique since 2002 without any problems at all.  I hope this helps your practice as well.

It is suitable for single or multiple restorations in a quadrant.  It can also be used when there are restorations in different quadrants.

Let me know if you have any questions or comments.

Download onlay_provisional_technique.ppt